Provider Demographics
NPI:1184965493
Name:ADDO-WALLACE, EVELYN (NP)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:ADDO-WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 REGAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1048
Mailing Address - Country:US
Mailing Address - Phone:917-297-1980
Mailing Address - Fax:336-900-1320
Practice Address - Street 1:165 BROADWAY FL 23
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1452
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF421131-1363LW0102X
NY659682-1163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331946Medicare Oscar/Certification
NY00695941Medicaid
NYG100000410Medicare Oscar/Certification