Provider Demographics
NPI:1356368849
Name:WALLACE, PATRICIA G (CNS)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4847 E VIRGINIA ST STE D
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2611
Mailing Address - Country:US
Mailing Address - Phone:812-479-1242
Mailing Address - Fax:812-479-1330
Practice Address - Street 1:4847 E VIRGINIA ST STE D
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2611
Practice Address - Country:US
Practice Address - Phone:812-479-1242
Practice Address - Fax:812-479-1330
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000099B364SP0808X
IN70000099A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000492046OtherANTHEM
IN247890DMedicare PIN
IN000000492046OtherANTHEM