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Individual
LA TANYA WALLACE
Active
Individual
LA TANYA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
680663
CA
363L00000X
Nurse Practitioner
22485
CA
363LF0000X
Family Nurse Practitioner
22485
CA
363LF0000X
Family Nurse Practitioner
680663
CA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
22485
CA
Other
Enumeration date
07/03/2008
Last updated
01/28/2024
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