MEDICARE: ALEXIA WALLACE ARNP

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	9287652	FL
2	363LF0000X	Family Nurse Practitioner	0024174328	VA

General Provider Information

NPI Number	:	1821455320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIA WALLACE ARNP

Provider Business Mailing Address
First Line	:	221 E HUNDRED RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23836-2613
Country	:	US
Telephone Number	:	804-530-1172
Fax Number	:

Provider Business Practice Location Address
First Line	:	221 E HUNDRED RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23836-2613
Country	:	US
Telephone Number	:	804-530-1172
Fax Number	:

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

Provider Enumeration Date	:	01/28/2016
Last Update Date	:	03/01/2017

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