Provider Demographics
NPI:1457334633
Name:WALLACE, WILLIAM S (FNP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41527
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38174-1527
Mailing Address - Country:US
Mailing Address - Phone:901-272-0003
Mailing Address - Fax:901-272-7179
Practice Address - Street 1:1200 PEABODY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4506
Practice Address - Country:US
Practice Address - Phone:901-272-0003
Practice Address - Fax:901-272-7179
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN108204163W00000X
TNRN108204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3388963Medicaid
TN4070262OtherBLUE CROSS
TN000000028284OtherTENNCARE TLC
TN3349986Medicare ID - Type Unspecified
TN4070262OtherBLUE CROSS