Individual
ANDREA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-C
Contact information
Practice address
5041 GOSWELL CV, OLIVE BRANCH, MS 38654-9189
(901) 517-2555
Mailing address
5041 GOSWELL CV, OLIVE BRANCH, MS 38654-9189
(901) 517-2555
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
30782
TN
Other
Enumeration date
12/09/2021
Last updated
07/06/2023
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