Provider Demographics
NPI:1841453487
Name:WALLACE, LA TANYA (FNP)
Entity type:Individual
Prefix:
First Name:LA TANYA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6921 SPERRY CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7030
Mailing Address - Country:US
Mailing Address - Phone:858-717-0164
Mailing Address - Fax:888-425-0508
Practice Address - Street 1:6921 SPERRY CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-7030
Practice Address - Country:US
Practice Address - Phone:858-717-0164
Practice Address - Fax:888-425-0508
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA680663163W00000X, 363LF0000X
CA22485363L00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680663OtherCA BRN
CA22485OtherBOARD OF REGISTERED NURSING