Provider Demographics
NPI:1992394423
Name:WALLACE, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2485
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-2485
Mailing Address - Country:US
Mailing Address - Phone:352-551-9404
Mailing Address - Fax:
Practice Address - Street 1:287 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8411
Practice Address - Country:US
Practice Address - Phone:352-747-0747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011114207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine