Provider Demographics
NPI:1679552871
Name:WALLACE, GAYLE M (ARNP)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:563-355-2244
Mailing Address - Fax:563-344-6701
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:STE 110
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3494
Practice Address - Country:US
Practice Address - Phone:563-355-2244
Practice Address - Fax:563-344-6701
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB096425363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S75323Medicare UPIN