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NPI Code Detail

MEDICARE: CHERRY WALLACE

MEDICARE: CHERRY WALLACE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LG0600XGerontology Nurse Practitioner2025047590MO

General Provider Information

NPI Number : 1013886456
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHERRY WALLACE
Provider Business Mailing Address
First Line : 905 CHESTNUT RIDGE RD
Second Line :
City : MANCHESTER
State : MO
Zip : 63021-6925
Country : US
Telephone Number : 314-536-1897
Fax Number : 314-536-1897
Provider Business Practice Location Address
First Line : 425 N NEW BALLAS RD STE 203
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63141-6848
Country : US
Telephone Number : 314-872-3104
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/03/2025
Last Update Date : 11/04/2025

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Directions to “ CHERRY WALLACE ” Practice Location

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