Provider Demographics
NPI:1649889478
Name:WALLACE, JELISA (CRNP)
Entity type:Individual
Prefix:
First Name:JELISA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 CUMBERLAND AVE SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-2611
Mailing Address - Country:US
Mailing Address - Phone:256-466-5717
Mailing Address - Fax:
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4421
Practice Address - Country:US
Practice Address - Phone:256-265-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF06200386363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily