Provider Demographics
NPI:1699323287
Name:WALLACE-WILSON, SHARON ROSE
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:ROSE
Last Name:WALLACE-WILSON
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 1:8800 ANDORA DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2559
Mailing Address - Country:US
Mailing Address - Phone:305-335-2603
Mailing Address - Fax:
Practice Address - Street 1:8800 ANDORA DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2559
Practice Address - Country:US
Practice Address - Phone:305-335-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9175068163W00000X
FL11003939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse