Individual
MRS. NICHOLE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
760 BROADWAY, BROOKLYN, NY 11206-5317
(718) 312-2312
Mailing address
833 PENFIELD ST, BRONX, NY 10470-1322
(718) 708-1913
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Enumeration date
07/06/2016
Last updated
08/18/2023
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