Provider Demographics
NPI:1346603925
Name:WALLIS, SUZANNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 CITRUS TOWER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1908
Mailing Address - Country:US
Mailing Address - Phone:352-394-3929
Mailing Address - Fax:
Practice Address - Street 1:265 CITRUS TOWER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1908
Practice Address - Country:US
Practice Address - Phone:352-394-3929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9331955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily