Basic Information
| Provider Information | |||||||||
| NPI: | 1235494196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | COWEN MANNING | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271647 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841271647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196674526 | ||||||||
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| Practice Location | |||||||||
| Address1: | N2198 UNC HOSPITALS | ||||||||
| Address2: | CB # 7010 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275997010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199665136 | ||||||||
| FaxNumber: | 9849744873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2012 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 219670 | NC | N | Nursing Service Providers | Registered Nurse | 367500000X | 91109 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.