Individual
KELLY ELIZABETH WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
200 MEDICAL PARK BLVD, PETERSBURG, VA 23805-9274
(804) 765-5000
Mailing address
2610 SETTING SUN DR, POWHATAN, VA 23139-7552
(910) 443-1679
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
0024183547
VA
Other
Enumeration date
01/19/2022
Last updated
01/27/2022
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