Provider Demographics
NPI:1033393780
Name:WALLACE, PATRICIA BONNER (MN, APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:BONNER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8429
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-8429
Mailing Address - Country:US
Mailing Address - Phone:252-758-4400
Mailing Address - Fax:252-752-4197
Practice Address - Street 1:823 EVANS ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3267
Practice Address - Country:US
Practice Address - Phone:252-758-4400
Practice Address - Fax:252-752-4197
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health