Provider Demographics
NPI:1851609945
Name:WALLACE, KRISTI (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 E 18TH AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4081
Mailing Address - Country:US
Mailing Address - Phone:541-343-3455
Mailing Address - Fax:541-735-3260
Practice Address - Street 1:74 E 18TH AVE
Practice Address - Street 2:STE 5
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4081
Practice Address - Country:US
Practice Address - Phone:541-255-2248
Practice Address - Fax:541-735-3260
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050185NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily