Provider Demographics
NPI:1679959852
Name:WALLACE, CLEOPATRA (CRNA)
Entity type:Individual
Prefix:
First Name:CLEOPATRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CLEOPATRA
Other - Middle Name:W
Other - Last Name:SHIRLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-2147
Practice Address - Fax:478-742-9670
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181636163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse