MEDICARE: AMANDA GAIL WALLACE

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	3011658	KY
2	363LF0000X	Family Nurse Practitioner	APRN.CNP.021126	OH
3	163W00000X	Registered Nurse	RN.300987	OH
4	163W00000X	Registered Nurse	1155351	KY

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1154844041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA GAIL WALLACE

Provider Business Mailing Address
First Line	:	6460 HARRISON AVE STE 200
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45247-7958
Country	:	US
Telephone Number	:	513-941-4999
Fax Number	:	513-694-0168

Provider Business Practice Location Address
First Line	:	247 CIC BLVD
Second Line	:
City	:	WEST UNION
State	:	OH
Zip	:	45693-7512
Country	:	US
Telephone Number	:	513-941-4999
Fax Number	:	513-694-0168

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

Provider Enumeration Date	:	07/21/2017
Last Update Date	:	05/05/2023

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308