Individual
DYLAN ELIZABETH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
3400 SPRUCE ST, PHILADELPHIA, PA 19104-4238
(215) 662-3920
Mailing address
3400 SPRUCE ST, PHILADELPHIA, PA 19104-4238
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
SP021955
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NA
N/A
—
Enumeration date
05/13/2020
Last updated
05/13/2020
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