Provider Demographics
NPI:1740703180
Name:WALLACE, MADISON (APN)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-7015
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1995 HIGHWAY 51 S STE 204
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3655
Practice Address - Country:US
Practice Address - Phone:901-475-5305
Practice Address - Fax:901-475-5307
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily