Provider Demographics
NPI:1164909339
Name:WALLACE, SONNY S (NP)
Entity Type:Individual
Prefix:
First Name:SONNY
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2319
Mailing Address - Country:US
Mailing Address - Phone:855-524-4001
Mailing Address - Fax:402-398-5589
Practice Address - Street 1:7500 MERCY RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:855-524-4001
Practice Address - Fax:402-398-5589
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH152173363L00000X
NE112565363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner