Provider Demographics
NPI:1588959522
Name:WALLACE, CRISTY L (FNP)
Entity type:Individual
Prefix:
First Name:CRISTY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-0205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-378-3699
Practice Address - Street 1:1651 W ROSEDALE ST STE 205
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-332-9966
Practice Address - Fax:817-332-9977
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7203111NN1001X
TX133N00000X
TXAP120370363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No111NN1001XChiropractic ProvidersChiropractorNutrition
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB163446Medicare PIN
TXTXB163939Medicare PIN
TXTXB163441Medicare PIN