1932430436 NPI number — LISA A WALLACE FNP

Table of content: DR. CHARLES WAYNE DICKERSON MD (NPI 1962433748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932430436 NPI number — LISA A WALLACE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALMEIDA
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932430436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 W 14TH ST
Provider Second Line Business Mailing Address:
WILMINGTON HOSPITAL, SUITE 5W67
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19801-1013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 W 14TH ST
Provider Second Line Business Practice Location Address:
SUITE 5W67
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19801-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-428-4900
Provider Business Practice Location Address Fax Number:
302-428-2663
Provider Enumeration Date:
01/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  LG-0000511 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: LG-0000511 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LG-0000511 . This is a "NP LICENSE NUMBER" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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