Provider Demographics
NPI:1083504740
Name:WALLACE, BROOKE MELANIE (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MELANIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:650 S GREEN VALLEY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-0425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 S GREEN VALLEY PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0425
Practice Address - Country:US
Practice Address - Phone:702-847-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-05
Last Update Date:2025-07-05
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant