MEDICARE: DR. CESALIE DEONNE WALLACE APN

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	A003758	AR

General Provider Information

NPI Number	:	1407104052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CESALIE DEONNE WALLACE APN

Provider Business Mailing Address
First Line	:	3000 N 1ST ST
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076-1802
Country	:	US
Telephone Number	:	501-982-7477
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 NORTH FIRST STREET
Second Line	:
City	:	JACKSONVILLE
State	:	AR
Zip	:	72076
Country	:	US
Telephone Number	:	501-982-7477
Fax Number	:

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

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	01/23/2026

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