Provider Demographics
NPI:1104305432
Name:WALLACE, HAILEY D (CRNA)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:D
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 CROSS POINTE RD STE C
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6692
Mailing Address - Country:US
Mailing Address - Phone:614-761-1255
Mailing Address - Fax:614-552-0168
Practice Address - Street 1:930 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1906
Practice Address - Country:US
Practice Address - Phone:614-451-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCRNA.019718367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered