Provider Demographics
NPI:1033982780
Name:WALLACE, ANNA (APRN)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N HIGHWAY 377
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6170
Mailing Address - Country:US
Mailing Address - Phone:682-237-7600
Mailing Address - Fax:
Practice Address - Street 1:208 N HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6170
Practice Address - Country:US
Practice Address - Phone:682-237-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty