Provider Demographics
NPI:1679133573
Name:WALLACE, ASHLEY LYNETTE (MSN, APRN, FNP-C,)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C,
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:LYNETTE
Other - Last Name:BONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, FNP-C
Mailing Address - Street 1:1400 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4110
Mailing Address - Country:US
Mailing Address - Phone:817-922-4630
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-922-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141896363L00000X
TXPENDING363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP141896OtherTEXAS BOARD OF NURSING