Basic Information
| Provider Information | |||||||||
| NPI: | 1417456989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DIONNE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUMPHREY | ||||||||
| OtherFirstName: | DIONNE | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 101 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HARDY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725429566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737182570 | ||||||||
| FaxNumber: | 8708562133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1016 N FOURCHE AVE | ||||||||
| Address2: | |||||||||
| City: | PERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721268545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012381284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2018 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A005504 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.