Provider Demographics
NPI:1194744623
Name:WALLACE, ANNE ELIZABETH (RN)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 MILL ST STE 301
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1484
Mailing Address - Country:US
Mailing Address - Phone:775-982-4948
Mailing Address - Fax:775-982-5240
Practice Address - Street 1:850 MILL ST STE 301
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1484
Practice Address - Country:US
Practice Address - Phone:775-982-4948
Practice Address - Fax:775-982-5240
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN18759163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507632Medicaid