Provider Demographics
NPI:1427534718
Name:WALLACE, STEPHANIE E (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 836
Mailing Address - Street 2:BOX 122
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09636
Mailing Address - Country:US
Mailing Address - Phone:570-573-4343
Mailing Address - Fax:
Practice Address - Street 1:PSC 836
Practice Address - Street 2:BOX 122
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09636
Practice Address - Country:US
Practice Address - Phone:570-573-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001092207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology