Provider Demographics
NPI:1326594144
Name:WALLACH, DEBORAH (FNP-BC, OCN, PMN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:WALLACH
Suffix:
Gender:F
Credentials:FNP-BC, OCN, PMN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 CAMINO REAL UNIT 102
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4301
Mailing Address - Country:US
Mailing Address - Phone:424-247-3150
Mailing Address - Fax:
Practice Address - Street 1:9090 WILSHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1850
Practice Address - Country:US
Practice Address - Phone:310-888-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004542363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily