Basic Information
| Provider Information | |||||||||
| NPI: | 1942804612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8552 DALTON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272847276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363026180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 719 GREEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362755391 | ||||||||
| FaxNumber: | 3362754702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5013821 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.