Provider Demographics
NPI:1962913293
Name:WALLACE, BENJAMIN LEVI (FNP-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:LEVI
Last Name:WALLACE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 PINE ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-5555
Mailing Address - Country:US
Mailing Address - Phone:936-222-1358
Mailing Address - Fax:
Practice Address - Street 1:264 FM 3478 RD
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77320-3322
Practice Address - Country:US
Practice Address - Phone:936-291-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134640363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily