Individual
STACY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
1702 N ALAMO ST, SUITE 220, SAN ANTONIO, TX 78215-1201
(210) 224-1823
(210) 224-7011
Mailing address
1702 N ALAMO ST, SUITE 220, SAN ANTONIO, TX 78215-1201
(210) 224-1823
(210) 224-7011
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
624860
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
181428701
—
TX
01
—
67466
CIDC
TX
Enumeration date
08/01/2006
Last updated
01/27/2010
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