Provider Demographics
NPI:1891301164
Name:WALLACE, TASHOY A (DNP, MSN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:TASHOY
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DNP, MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 KUHL AVE # MP38
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:321-842-4713
Mailing Address - Fax:
Practice Address - Street 1:89 W COPELAND DR FL 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-841-7550
Practice Address - Fax:321-841-8185
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205003363LA2100X
FLAPRN11016381363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care