Provider Demographics
NPI:1013349000
Name:WALLACE, LISA (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ACNP
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6338
Practice Address - Country:US
Practice Address - Phone:864-454-4200
Practice Address - Fax:864-454-4205
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-14866363LA2100X
SC28748363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care