Provider Demographics
NPI:1679708556
Name:WALLACE, PHYLLIS MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E. SHERWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511
Mailing Address - Country:US
Mailing Address - Phone:832-621-6220
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 600
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-796-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX561885163W00000X
TXAP117949367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse