Provider Demographics
NPI:1720829468
Name:WALLACE, CAMILLE ANNE (FNP)
Entity type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:ANNE
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 1:45 BIRCH ST APT 18K
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1077
Mailing Address - Country:US
Mailing Address - Phone:845-489-1073
Mailing Address - Fax:
Practice Address - Street 1:404 ZENA RD STE 1
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2627
Practice Address - Country:US
Practice Address - Phone:845-679-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354716363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily