Provider Demographics
NPI:1861558835
Name:WALLACE-MARCELLE, CAYLYNN ANN (ARNP, CPNP)
Entity type:Individual
Prefix:MS
First Name:CAYLYNN
Middle Name:ANN
Last Name:WALLACE-MARCELLE
Suffix:
Gender:F
Credentials:ARNP, CPNP
Other - Prefix:MS
Other - First Name:CAYLYNN
Other - Middle Name:ANN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2497 7TH AVENUE E
Mailing Address - Street 2:STE 108
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2946
Mailing Address - Country:US
Mailing Address - Phone:651-769-6437
Mailing Address - Fax:651-769-6599
Practice Address - Street 1:8441 WAYZATA BLVD
Practice Address - Street 2:STE 140
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1366
Practice Address - Country:US
Practice Address - Phone:651-769-6300
Practice Address - Fax:651-769-6349
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR180936-5363LP0200X
MN1809365363LP0808X
MN955363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1861558835Medicaid