Provider Demographics
NPI:1407516669
Name:WALLACE, KERRI (DNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 COUNTY ROAD 521
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650-8553
Mailing Address - Country:US
Mailing Address - Phone:256-318-6278
Mailing Address - Fax:
Practice Address - Street 1:10939 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-1914
Practice Address - Country:US
Practice Address - Phone:256-974-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-159583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily