Individual
BERNICE E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4101 NW 4TH ST, SUITE 200, PLANTATION, FL 33317-2850
(954) 791-5420
(954) 791-5950
Mailing address
4101 NW 4TH ST, SUITE 200, PLANTATION, FL 33317-2850
(954) 791-5420
(954) 791-5950
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
ARNP1772012
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
302604300
—
FL
Enumeration date
07/30/2010
Last updated
02/16/2012
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