Provider Demographics
NPI:1528787744
Name:WALLACE, DANE C (NURSE PRACTITIONER)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 HILLSBORO AVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1864
Mailing Address - Country:US
Mailing Address - Phone:217-621-8675
Mailing Address - Fax:
Practice Address - Street 1:529 HILLSBORO AVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1864
Practice Address - Country:US
Practice Address - Phone:217-621-8675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025563363LF0000X
MO2023036829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily