Provider Demographics
NPI:1659646768
Name:WALLACE, CARRIE B (ANP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:BETH
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 DOWELL SPRINGS BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909
Mailing Address - Country:US
Mailing Address - Phone:865-637-8812
Mailing Address - Fax:865-637-8865
Practice Address - Street 1:122 KENT PLACE
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701
Practice Address - Country:US
Practice Address - Phone:865-637-8812
Practice Address - Fax:865-342-4678
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16556363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005787Medicaid