MEDICARE: CHIARA 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
1	363LF0000X	Family Nurse Practitioner	11624749-4405	UT
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1073243481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIARA WALLACE

Provider Business Mailing Address
First Line	:	961 E CRANDALL AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2107
Country	:	US
Telephone Number	:	612-770-9037
Fax Number	:

Provider Business Practice Location Address
First Line	:	961 E CRANDALL AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2107
Country	:	US
Telephone Number	:	612-770-9037
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2022
Last Update Date	:	12/08/2024

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Directions to “ CHIARA WALLACE ” Practice Location

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