Provider Demographics
NPI:1497027247
Name:WALLACE, MELISSA B (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:B
Last Name:WALLACE
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Gender:F
Credentials:WHNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8064
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-0800
Mailing Address - Fax:314-747-4019
Practice Address - Street 1:4901 FOREST PARK AVE STE 710
Practice Address - Street 2:STE 710
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1402
Practice Address - Country:US
Practice Address - Phone:314-362-4211
Practice Address - Fax:314-362-0049
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2018-01-29
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Provider Licenses
StateLicense IDTaxonomies
MO151045363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid