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NPI Code Detail

MEDICARE: MS. CAMILLE ANNE WALLACE FNP

MEDICARE: MS. CAMILLE ANNE WALLACE FNP
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 Practitioner354716NY

General Provider Information

NPI Number : 1720829468
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CAMILLE ANNE WALLACE FNP
Provider Business Mailing Address
First Line : 45 BIRCH ST APT 18K
Second Line :
City : KINGSTON
State : NY
Zip : 12401-1077
Country : US
Telephone Number : 845-489-1073
Fax Number :
Provider Business Practice Location Address
First Line : 404 ZENA RD STE 1
Second Line :
City : WOODSTOCK
State : NY
Zip : 12498-2627
Country : US
Telephone Number : 845-679-5271
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/05/2024
Last Update Date : 07/04/2024

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