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NPI Code Detail

MEDICARE: MS. BETH IRENE WALLACE FNP-BC

MEDICARE: MS. BETH IRENE WALLACE FNP-BC
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 PractitionerARNP 9399487FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1871906909
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. BETH IRENE WALLACE FNP-BC
Provider Business Mailing Address
First Line : 4354 NW 23RD AVE # AVW
Second Line :
City : GAINESVILLE
State : FL
Zip : 32606-6541
Country : US
Telephone Number : 352-376-4565
Fax Number :
Provider Business Practice Location Address
First Line : 4354 NW 23RD AVE # AVW
Second Line :
City : GAINESVILLE
State : FL
Zip : 32606-6541
Country : US
Telephone Number : 352-376-4565
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/05/2014
Last Update Date : 05/15/2022

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