Provider Demographics
NPI:1417176546
Name:WALLACE, MARY MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N 44TH ST
Mailing Address - Street 2:#200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7624
Mailing Address - Country:US
Mailing Address - Phone:602-685-3846
Mailing Address - Fax:602-685-3808
Practice Address - Street 1:444 N 44TH ST
Practice Address - Street 2:#200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7624
Practice Address - Country:US
Practice Address - Phone:602-685-3846
Practice Address - Fax:602-685-3808
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN030118363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ637184Medicaid
AZS67140Medicare UPIN
AZ102039Medicare ID - Type Unspecified