Individual
MS. LA' TAYSIA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MSN, RN, CPNP-PC
Contact information
Practice address
21 PENNY DR, HUNTINGTON STATION, NY 11746-3422
(516) 850-9623
Mailing address
PO BOX 3644, MOUNT VERNON, NY 10553-3644
(516) 850-9623
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
716807-1
NY
164W00000X
Licensed Practical Nurse
308886-1
NY
363LP0200X
Pediatric Nurse Practitioner
Primary
F383676-01
NY
Other
Enumeration date
01/10/2012
Last updated
04/02/2024
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