Provider Demographics
NPI:1548951411
Name:WALLACE, SAMANTHA (CRNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 HARMONY RD APT A
Mailing Address - Street 2:
Mailing Address - City:BADEN
Mailing Address - State:PA
Mailing Address - Zip Code:15005-1132
Mailing Address - Country:US
Mailing Address - Phone:724-650-4974
Mailing Address - Fax:
Practice Address - Street 1:4100 ALLEQUIPPA STREET
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15240
Practice Address - Country:US
Practice Address - Phone:412-822-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN697368163W00000X
PASP027326363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse