Provider Demographics
NPI:1003414228
Name:WALLACE, CHELSEA ROSE (RN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHELSEA
Middle Name:ROSE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9976 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9769
Mailing Address - Country:US
Mailing Address - Phone:208-229-3742
Mailing Address - Fax:
Practice Address - Street 1:9976 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9769
Practice Address - Country:US
Practice Address - Phone:208-229-3742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner