Individual
DR. DANE C WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NURSE PRACTITIONER
Contact information
Practice address
529 HILLSBORO AVE, EDWARDSVILLE, IL 62025-1864
(217) 621-8675
Mailing address
529 HILLSBORO AVE, EDWARDSVILLE, IL 62025-1864
(217) 621-8675
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
2023036829
MO
363LF0000X
Family Nurse Practitioner
Primary
209.025563
IL
Other
Enumeration date
08/22/2022
Last updated
11/06/2023
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