Provider Demographics
NPI:1689640195
Name:WALLACE, VICKI (NP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SAM PERRY BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401
Mailing Address - Country:US
Mailing Address - Phone:540-372-7792
Mailing Address - Fax:540-372-2073
Practice Address - Street 1:1101 SAM PERRY BLVD.,
Practice Address - Street 2:SUITE 211
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-372-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN67063363L00000X
VA0024166526363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036084100Medicaid
DC405959000Medicaid
DCP00205521Medicare ID - Type UnspecifiedRAILROAD MEDICARE
DC036084100Medicaid
DCQ18521Medicare UPIN
DC405959000Medicaid