Provider Demographics
NPI:1114700739
Name:WALLACE, TYLER J (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 LONE OAK RD STE 345
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7942
Mailing Address - Country:US
Mailing Address - Phone:270-444-2250
Mailing Address - Fax:
Practice Address - Street 1:1532 LONE OAK RD STE 345
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7942
Practice Address - Country:US
Practice Address - Phone:270-444-2250
Practice Address - Fax:270-538-6596
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4005513363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty