Provider Demographics
NPI:1669719175
Name:WALLACE, RACHEL RENEE (CRNA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35505 ROAD K.1
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-8978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311 N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:970-555-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0088890367500000X
COC-APN.0001428-C-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered