Provider Demographics
NPI:1861989279
Name:WALLACE, DANA MARIE (CRNP FNP-C)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-2802
Mailing Address - Country:US
Mailing Address - Phone:484-477-5063
Mailing Address - Fax:
Practice Address - Street 1:5040 CITY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1435
Practice Address - Country:US
Practice Address - Phone:215-877-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily