Provider Demographics
NPI:1417456989
Name:WALLACE, DIONNE H (CNP)
Entity Type:Individual
Prefix:
First Name:DIONNE
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:DIONNE
Other - Middle Name:H
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9566
Mailing Address - Country:US
Mailing Address - Phone:573-718-2570
Mailing Address - Fax:870-856-2133
Practice Address - Street 1:1016 N FOURCHE AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72126-8545
Practice Address - Country:US
Practice Address - Phone:501-238-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily