Provider Demographics
NPI:1265648596
Name:WALLACE, CARRIE LEIGH (FNP)
Entity Type:Individual
Prefix:MISS
First Name:CARRIE
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19001 FAIRHAVEN EXT
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-1359
Mailing Address - Country:US
Mailing Address - Phone:714-633-8187
Mailing Address - Fax:
Practice Address - Street 1:455 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3835
Practice Address - Country:US
Practice Address - Phone:714-289-4934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily