Provider Demographics
NPI:1922210343
Name:WALLACE, JUDITH MARY (RXN,NP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:MARY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RXN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31371 LOGES LN
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9460
Mailing Address - Country:US
Mailing Address - Phone:303-674-7603
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9583
Practice Address - Country:US
Practice Address - Phone:303-673-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96216363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care