Provider Demographics
NPI:1043731615
Name:FOX, WALLACE DALE JR (APRN)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:DALE
Last Name:FOX
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
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Mailing Address - Street 1:1400 MAIN ST UNIT 177
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-3108
Mailing Address - Country:US
Mailing Address - Phone:812-946-2674
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN ST UNIT 177
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-3108
Practice Address - Country:US
Practice Address - Phone:812-946-2674
Practice Address - Fax:844-832-9625
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71007238A363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily