Provider Demographics
NPI:1346740578
Name:WALLACE, MERIT (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MERIT
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:MERIT
Other - Middle Name:
Other - Last Name:GOSPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:8300 ESTERS BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2233
Mailing Address - Country:US
Mailing Address - Phone:415-424-4266
Mailing Address - Fax:415-520-6633
Practice Address - Street 1:10775 PIONEER TRL STE 215
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0234
Practice Address - Country:US
Practice Address - Phone:415-424-4266
Practice Address - Fax:415-520-6633
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0012823363LF0000X
MARN2364003363LF0000X
AZ273273363LF0000X
CA95028713363LF0000X
MDAC004245363LF0000X
MECNP241144363LF0000X
NDR56197363LF0000X
NE115469363LF0000X
MN9335363LF0000X
NC5016900363LF0000X
NH087031-23363LF0000X
OR202201157NP-PP363LF0000X
TX1024045363LF0000X
VA0024183216363LF0000X
FLAPRN9297649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023994500Medicaid