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NPI Code Detail

MEDICARE: MICHELLE DIANNE WALLACE FNP-C

MEDICARE: MICHELLE DIANNE WALLACE FNP-C
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
1363LF0000XFamily Nurse Practitioner28184348AIN

General Provider Information

NPI Number : 1316471790
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLE DIANNE WALLACE FNP-C
Provider Business Mailing Address
First Line : 8970 S MERIDIAN ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46217-5031
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 8970 S MERIDIAN ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46217-5031
Country : US
Telephone Number : 317-374-7779
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/12/2017
Last Update Date : 04/15/2017

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