Provider Demographics
NPI:1952818403
Name:WALLACE, TAMYRA (FNP)
Entity Type:Individual
Prefix:
First Name:TAMYRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TAMYRA
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:8189 MIDTOWN BLVD APT 12217
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4561
Mailing Address - Country:US
Mailing Address - Phone:337-201-1875
Mailing Address - Fax:
Practice Address - Street 1:8189 MIDTOWN BLVD APT 12217
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:337-201-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135378363LF0000X
TNAP135378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily