Provider Demographics
NPI:1932473386
Name:WALLACE, JASMIA NYREE (FNP)
Entity Type:Individual
Prefix:MS
First Name:JASMIA
Middle Name:NYREE
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:PO BOX 25371
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:426 21ST AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2424
Practice Address - Country:US
Practice Address - Phone:615-321-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217995363LF0000X
TN16419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily