MEDICARE: PATRICIA WALLACE RN

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	163WW0000X	Wound Care Registered Nurse	RN-88042	NM

General Provider Information

NPI Number	:	1861227126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA WALLACE RN

Provider Business Mailing Address
First Line	:	2211 LOMAS BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-2719
Country	:	US
Telephone Number	:	505-272-2231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 LOMAS BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-2719
Country	:	US
Telephone Number	:	505-272-2231
Fax Number	:

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

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	06/01/2026

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