Provider Demographics
NPI:1104169911
Name:WALLACE, HAROLYN (ANP)
Entity type:Individual
Prefix:
First Name:HAROLYN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12223 BROOKVALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071-2702
Mailing Address - Country:US
Mailing Address - Phone:832-724-4762
Mailing Address - Fax:
Practice Address - Street 1:201 MARIPOSA
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4177
Practice Address - Country:US
Practice Address - Phone:361-664-8811
Practice Address - Fax:361-664-8992
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122716363LF0000X
TX600813363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8396NAOtherBCBS
TX320242601Medicaid
TX320242601Medicaid