Provider Demographics
NPI:1679887707
Name:WALLACE, BERNICE E
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 NW 4TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2850
Mailing Address - Country:US
Mailing Address - Phone:954-791-5420
Mailing Address - Fax:954-791-5950
Practice Address - Street 1:4101 NW 4TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2850
Practice Address - Country:US
Practice Address - Phone:954-791-5420
Practice Address - Fax:954-791-5950
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1772012363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302604300Medicaid