Provider Demographics
NPI:1770006538
Name:WALLACE, DEBRA ANN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4632 E VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1545
Mailing Address - Country:US
Mailing Address - Phone:323-409-7788
Mailing Address - Fax:323-441-7298
Practice Address - Street 1:1100 N STATE STREET
Practice Address - Street 2:CLINIC TOWER A6A231A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-409-7788
Practice Address - Fax:323-441-7298
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83262086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherMEDICARE