Provider Demographics
NPI:1912149188
Name:WALLACE, DEBRA ANN
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5608 KENNY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-7711
Mailing Address - Country:US
Mailing Address - Phone:813-546-4884
Mailing Address - Fax:813-983-1860
Practice Address - Street 1:5608 KENNY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-7711
Practice Address - Country:US
Practice Address - Phone:813-546-4884
Practice Address - Fax:813-983-1860
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6842062963747A0650X, 3747P1801X, 372600000X
FLCNA 54979376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14627300Medicaid
FLCNA54979OtherCNA
FL684206296Medicaid