Provider Demographics
NPI:1780665521
Name:WALLACE, MARLENE T (RN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, FNP-C
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Other - Middle Name:
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Mailing Address - Street 1:5808 MCWHORTER RD
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-8202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1142 N BROOME ST
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-9378
Practice Address - Country:US
Practice Address - Phone:704-843-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201319363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2599293BMedicare PIN