Provider Demographics
NPI:1336967363
Name:WALLACE, DANI PAIGE (APN)
Entity type:Individual
Prefix:
First Name:DANI
Middle Name:PAIGE
Last Name:WALLACE
Suffix:
Gender:
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-2235
Mailing Address - Country:US
Mailing Address - Phone:609-402-5008
Mailing Address - Fax:
Practice Address - Street 1:3003 ENGLISH CREEK AVE STE C6
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-4818
Practice Address - Country:US
Practice Address - Phone:609-481-3185
Practice Address - Fax:609-569-0104
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15163900363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics