Provider Demographics
NPI:1659978328
Name:LA TANYA WALLACE, NURSE PRACTITIONER & ASSOCIATES, INCORPORATED
Entity Type:Organization
Organization Name:LA TANYA WALLACE, NURSE PRACTITIONER & ASSOCIATES, INCORPORATED
Other - Org Name:LA TANYA WALLACE, NP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LA TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:619-398-7473
Mailing Address - Street 1:6921 SPERRY CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7030
Mailing Address - Country:US
Mailing Address - Phone:619-398-7473
Mailing Address - Fax:888-425-0508
Practice Address - Street 1:3356 2ND AVE STE G
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5636
Practice Address - Country:US
Practice Address - Phone:858-717-0164
Practice Address - Fax:888-425-0508
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA TANYA WALLACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-06
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty