MEDICARE: MRS. KIMBERLY VERONICA WALLACE CNM APRN

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	367A00000X	Advanced Practice Midwife	APRN.CNM.019392	OH

General Provider Information

NPI Number	:	1144881640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY VERONICA WALLACE CNM APRN

Provider Business Mailing Address
First Line	:	3574 MELROSE DR
Second Line	:
City	:	WOOSTER
State	:	OH
Zip	:	44691-1857
Country	:	US
Telephone Number	:	614-370-1035
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 LILLIAN GISH BLVD SW STE 201
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44647-6500
Country	:	US
Telephone Number	:	330-809-0460
Fax Number	:

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

Provider Enumeration Date	:	06/25/2019
Last Update Date	:	01/12/2022

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