Provider Demographics
NPI:1871906909
Name:WALLACE, BETH IRENE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:BETH
Middle Name:IRENE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:IRENE
Other - Last Name:SPINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4354 NW 23RD AVE # AVW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6541
Mailing Address - Country:US
Mailing Address - Phone:352-376-4565
Mailing Address - Fax:
Practice Address - Street 1:4354 NW 23RD AVE # AVW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6541
Practice Address - Country:US
Practice Address - Phone:352-376-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9399487363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily