Provider Demographics
NPI:1881369536
Name:WALLACE, ASHLEIGH MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ASHLEIGH
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9306 FOREST POINT CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4700
Mailing Address - Country:US
Mailing Address - Phone:703-330-3322
Mailing Address - Fax:
Practice Address - Street 1:9306 FOREST POINT CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4700
Practice Address - Country:US
Practice Address - Phone:703-330-3322
Practice Address - Fax:703-330-3322
Is Sole Proprietor?:No
Enumeration Date:2021-08-14
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182364363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner