Provider Demographics
NPI:1336990019
Name:KIM MARIE WALLACE NP IN FAMILY HEALTH PLLC
Entity Type:Organization
Organization Name:KIM MARIE WALLACE NP IN FAMILY HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE-SCHLICK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:631-375-4211
Mailing Address - Street 1:20 DUNN CT
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2002
Mailing Address - Country:US
Mailing Address - Phone:631-375-4211
Mailing Address - Fax:833-605-4049
Practice Address - Street 1:20 DUNN CT
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2002
Practice Address - Country:US
Practice Address - Phone:631-375-4211
Practice Address - Fax:833-605-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty