Provider Demographics
NPI:1891288742
Name:WALLACE, CARIN LYNNAE (FNP)
Entity Type:Individual
Prefix:
First Name:CARIN
Middle Name:LYNNAE
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 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-7081
Practice Address - Street 1:825 MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2143
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-7081
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137578363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily