Provider Demographics
NPI:1417456989
Name:WALLACE, DIONNE H (CNP)
Entity type:Individual
Prefix:
First Name:DIONNE
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:DIONNE
Other - Middle Name:H
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1900 CLUB MANOR DR STE 105
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7443
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:
Practice Address - Street 1:1900 CLUB MANOR DR STE 105
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7443
Practice Address - Country:US
Practice Address - Phone:501-851-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily