Provider Demographics
NPI:1073584652
Name:WALLACE, ANGELA M (NP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:R
Other - Last Name:MASSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9300 DEWITT LOOP DEPT OF
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:571-231-1015
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP DEPT OF
Practice Address - Street 2:
Practice Address - City:FT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:571-231-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024093871363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care