Provider Demographics
NPI:1942804612
Name:WALLACE, TIFFANY (DNP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8552 DALTON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7276
Mailing Address - Country:US
Mailing Address - Phone:336-302-6180
Mailing Address - Fax:
Practice Address - Street 1:719 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7014
Practice Address - Country:US
Practice Address - Phone:336-275-5391
Practice Address - Fax:336-275-4702
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013821363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner