Provider Demographics
NPI:1952424525
Name:WALLACE, MAUREEN KAY (RNFA)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:KAY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 REGENT CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3968
Mailing Address - Country:US
Mailing Address - Phone:281-491-7363
Mailing Address - Fax:
Practice Address - Street 1:6624 FANNIN ST
Practice Address - Street 2:SUITE 2400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2312
Practice Address - Country:US
Practice Address - Phone:713-790-9151
Practice Address - Fax:713-790-0927
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX579570363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical