Individual
JENNIFER LEA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
625 6TH AVE S, SUITE 385, SAINT PETERSBURG, FL 33701-4662
(727) 553-7100
(727) 553-7198
Mailing address
625 6TH AVE S, SUITE 385, SAINT PETERSBURG, FL 33701-4662
(727) 553-7100
(727) 553-7198
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA9105134
FL
363AS0400X
Surgical Physician Assistant
PA9105134
FL
Other
Enumeration date
01/04/2006
Last updated
10/08/2015
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