Provider Demographics
NPI:1205222619
Name:WALLACE, EVA ANNMAE (RN)
Entity Type:Individual
Prefix:MS
First Name:EVA
Middle Name:ANNMAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 NE 22ND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-4761
Mailing Address - Country:US
Mailing Address - Phone:352-369-7860
Mailing Address - Fax:
Practice Address - Street 1:1539 NE 22ND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-4761
Practice Address - Country:US
Practice Address - Phone:352-369-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9208381163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9208381OtherRN LICENSE