Provider Demographics
NPI:1104810134
Name:WALLACE, REBECCA (APRN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3103
Mailing Address - Country:US
Mailing Address - Phone:801-487-4160
Mailing Address - Fax:
Practice Address - Street 1:3838 S 700 E
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1466
Practice Address - Country:US
Practice Address - Phone:801-261-4988
Practice Address - Fax:801-269-9427
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT216162-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1948Medicaid
UT005582313Medicare ID - Type Unspecified
UTP17963Medicare UPIN