Provider Demographics
NPI:1881856615
Name:WALLACE, ANGIE MARIE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:ANGIE
Other - Middle Name:MARIE
Other - Last Name:BORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:22 ST PAUL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1033
Mailing Address - Country:US
Mailing Address - Phone:717-709-7922
Mailing Address - Fax:717-263-2055
Practice Address - Street 1:45 ROADSIDE AVE FRNT
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2543
Practice Address - Country:US
Practice Address - Phone:717-387-8060
Practice Address - Fax:717-387-8061
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009803364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics