Provider Demographics
NPI:1326073040
Name:WALLACE, NICKOLA KIM (CRNP)
Entity Type:Individual
Prefix:MS
First Name:NICKOLA
Middle Name:KIM
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:NICKOLA
Other - Middle Name:KIM
Other - Last Name:MCCARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-6969
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:BLDG MKB
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17405
Practice Address - Country:US
Practice Address - Phone:717-851-2521
Practice Address - Fax:717-851-3535
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006718B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50048998OtherCAPITAL BLUE CROSS
PA050483EZ3Medicare ID - Type UnspecifiedPA MEDICARE
PAP38551Medicare UPIN