Provider Demographics
NPI:1366652364
Name:WALLACE, SYLVIA FAE (APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:SYLVIA
Middle Name:FAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
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Mailing Address - Street 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8820
Mailing Address - Fax:352-674-8919
Practice Address - Street 1:1575 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-6820
Practice Address - Country:US
Practice Address - Phone:352-674-1740
Practice Address - Fax:352-674-8940
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN1957902363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP46151Medicare UPIN
FLE6354SMedicare PIN