Provider Demographics
NPI:1013617711
Name:WALLACE, CAREECIA (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:CAREECIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 N STATE ROAD 7 STE B
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5713
Mailing Address - Country:US
Mailing Address - Phone:754-368-2586
Mailing Address - Fax:954-368-8517
Practice Address - Street 1:2155 N STATE ROAD 7 STE B
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5713
Practice Address - Country:US
Practice Address - Phone:754-368-2586
Practice Address - Fax:954-368-8517
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
FLRN9407773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty