Provider Demographics
NPI:1558256594
Name:WALLACE, TRENEICE
Entity type:Individual
Prefix:
First Name:TRENEICE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14511 MACADAMIA LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-1980
Mailing Address - Country:US
Mailing Address - Phone:954-607-8406
Mailing Address - Fax:
Practice Address - Street 1:7487 S STATE ROAD 121 # A
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-5451
Practice Address - Country:US
Practice Address - Phone:904-330-2572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9176588163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult