Provider Demographics
NPI:1114297074
Name:WALLACE, LA' TAYSIA (MSN, RN, CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:LA' TAYSIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3644
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-3644
Mailing Address - Country:US
Mailing Address - Phone:516-850-9623
Mailing Address - Fax:
Practice Address - Street 1:21 PENNY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3422
Practice Address - Country:US
Practice Address - Phone:516-850-9623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY716807-1163W00000X
NY308886-1164W00000X
NYF383676-01363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse