Provider Demographics
NPI:1093460412
Name:WALLACE, ALONA (APRN)
Entity Type:Individual
Prefix:
First Name:ALONA
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 1:1078 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-4411
Mailing Address - Country:US
Mailing Address - Phone:813-451-5701
Mailing Address - Fax:
Practice Address - Street 1:900 PINE ST UNIT 216-217
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4418
Practice Address - Country:US
Practice Address - Phone:941-474-5093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018027208000000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics