Provider Demographics
NPI:1982159356
Name:WALLACE, ELIZABETH ANN (FNP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1382
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:2001 LAUREL AVE STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1867
Practice Address - Country:US
Practice Address - Phone:865-577-9247
Practice Address - Fax:833-908-2095
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21538363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner