Provider Demographics
NPI:1336251560
Name:WALLACE, EMERSON AKALEE (CFNP)
Entity Type:Individual
Prefix:MR
First Name:EMERSON
Middle Name:AKALEE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:118 CR1810
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866
Mailing Address - Country:US
Mailing Address - Phone:662-844-6596
Mailing Address - Fax:
Practice Address - Street 1:1154 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-5777
Practice Address - Country:US
Practice Address - Phone:662-840-8010
Practice Address - Fax:662-840-2656
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR759298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0117978Medicaid
MS0117978Medicaid