Provider Demographics
NPI:1346236122
Name:WALLACE, DONNA C (PNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-3632
Mailing Address - Fax:602-406-6126
Practice Address - Street 1:2910 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:602-406-3632
Practice Address - Fax:602-406-6126
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN041572363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ70047Medicare ID - Type Unspecified
P58802Medicare UPIN