Provider Demographics
NPI:1568911675
Name:WALLACE, CHRISTINA ANN (CNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ANN
Other - Last Name:MORMILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:9293 STATE ROUTE 43
Mailing Address - Street 2:SUITE B
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5374
Mailing Address - Country:US
Mailing Address - Phone:330-626-1113
Mailing Address - Fax:330-626-1133
Practice Address - Street 1:1144 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1039
Practice Address - Country:US
Practice Address - Phone:614-234-0200
Practice Address - Fax:614-234-0201
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019939363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology