Individual
MRS. CYNTHIA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGPCNP
Contact information
Practice address
1111 CRATER LAKE AVE, MEDFORD, OR 97504-6241
(541) 732-5250
(541) 732-5251
Mailing address
PO BOX 3308, PORTLAND, OR 97208-3308
(541) 732-5250
(541) 732-5152
Taxonomy
Speciality
Code
Description
License number
State
363LG0600X
Gerontology Nurse Practitioner
Primary
201500016NP-PP
OR
Other
Enumeration date
11/05/2014
Last updated
09/30/2020
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