Basic Information
| Provider Information | |||||||||
| NPI: | 1669070694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295015151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034604424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 E CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437772000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2020 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 23696 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.