Provider Demographics
NPI:1285930123
Name:WALLACE, PEGGY LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-6015
Mailing Address - Country:US
Mailing Address - Phone:813-857-2679
Mailing Address - Fax:
Practice Address - Street 1:4600 N HABANA AVE
Practice Address - Street 2:SUITE 15
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7112
Practice Address - Country:US
Practice Address - Phone:813-870-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9274861363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health