Provider Demographics
NPI:1104000199
Name:WALLACE, SUSAN ANN
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:HAYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:17501 DALE MABRY HWY N
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4521
Mailing Address - Country:US
Mailing Address - Phone:813-962-1000
Mailing Address - Fax:
Practice Address - Street 1:17501 DALE MABRY HWY N
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-962-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3262052363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health