Provider Demographics
NPI:1972352821
Name:WALLACE, CYNEICEYA ANNETTE (MSN, APRN, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:CYNEICEYA
Middle Name:ANNETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSN, APRN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 KEESLER ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3216
Mailing Address - Country:US
Mailing Address - Phone:662-299-9832
Mailing Address - Fax:
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:662-459-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906657363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health