Provider Demographics
NPI:1184650970
Name:WILLIAMS-WALLACE, NANCY E (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:E
Last Name:WILLIAMS-WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2559 CENTENNIAL FALCON DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6310
Mailing Address - Country:US
Mailing Address - Phone:813-299-4931
Mailing Address - Fax:727-772-6891
Practice Address - Street 1:36422 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1330
Practice Address - Country:US
Practice Address - Phone:727-772-7712
Practice Address - Fax:727-772-6891
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69004207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378657900Medicaid
FLF19311Medicare UPIN
FL27890Medicare ID - Type Unspecified