Provider Demographics
NPI:1811393648
Name:WALLACE, CYNTHIA (AGPCNP)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3308
Mailing Address - Country:US
Mailing Address - Phone:541-732-5250
Mailing Address - Fax:541-732-5152
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:541-732-5250
Practice Address - Fax:541-732-5251
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500016NP-PP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology