Provider Demographics
NPI:1851960421
Name:WALLACE, CHARLESTON BAILEE (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLESTON
Middle Name:BAILEE
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 1:595 NATCHEZ TRACE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-1627
Mailing Address - Country:US
Mailing Address - Phone:731-307-9413
Mailing Address - Fax:
Practice Address - Street 1:157 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-2011
Practice Address - Country:US
Practice Address - Phone:731-968-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225188163W00000X
TN30307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse