Individual
KYLE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2015 GRAND CONCOURSE, BRONX, NY 10453-4303
(718) 583-7736
(718) 537-6180
Mailing address
2626 HALPERIN AVE, BRONX, NY 10461-2631
(718) 618-0401
(347) 479-1303
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
546269-1
NY
363LA2200X
Adult Health Nurse Practitioner
Primary
F311097-01
NY
Other
Enumeration date
01/10/2014
Last updated
11/14/2024
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