Provider Demographics
NPI:1629037676
Name:WALLACE, MARLENE MB (CRNA)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:MB
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
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Mailing Address - Street 1:5955 ZEAMER AVE
Mailing Address - Street 2:673RD MEDICAL GROUP/SGHQ DOD-VA JOINT VENTURE HOSPITAL
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-580-1035
Mailing Address - Fax:907-580-3203
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:673RD MEDICAL GROUP/SGHQ DOD-VA JOINT VENTURE HOSPITAL
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-1035
Practice Address - Fax:907-580-3203
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-02-13
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Provider Licenses
StateLicense IDTaxonomies
IL041305554163WP0000X
IL209012095367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WP0000XNursing Service ProvidersRegistered NursePain Management