Basic Information
| Provider Information | |||||||||
| NPI: | 1568911675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORMILE | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9293 STATE ROUTE 43 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | STREETSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442415374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306261113 | ||||||||
| FaxNumber: | 3306261133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1144 DUBLIN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432151039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142340200 | ||||||||
| FaxNumber: | 6142340201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2016 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN.CNP.019939 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.