Provider Demographics
NPI:1073540175
Name:WALLACE, AMY M (CNM)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:SHEARER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:590 NEW WAVERLY PL
Mailing Address - Street 2:210
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7407
Mailing Address - Country:US
Mailing Address - Phone:720-418-8186
Mailing Address - Fax:
Practice Address - Street 1:7777 W 38TH AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6168
Practice Address - Country:US
Practice Address - Phone:720-418-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101447367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07014475Medicaid
COC804577Medicare PIN
CO07014475Medicaid