Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 0024093871 | VA |
NPI | 1073584652 |
---|---|
Provider Name | Ms. Angela M Wallace |
First Address | Fort Belvoir, VA 22060-5285 |
Second Address | Ft Belvoir, VA 22060-5285 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2006 |
Last Update Date | 28/02/2018 |