Individual
RAFAELLA IZAR WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ANP
Contact information
Practice address
500 S HENDERSON ST STE 200, FORT WORTH, TX 76104-2154
(817) 413-1500
(817) 413-1499
Mailing address
PO BOX 911230, DALLAS, TX 75391-1230
(972) 997-8000
(972) 234-2987
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
AP129253
TX
363LG0600X
Gerontology Nurse Practitioner
Primary
AP129253
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
365509402
—
TX
01
—
8449NZ
BLUE CROSS BLUE SHIELD
TX
Enumeration date
10/13/2015
Last updated
12/01/2021
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