| NPI | 1366202194 |
|---|---|
| Former Name | TIFFANY LYNN WALLACE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: SD CP003284) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SD R050559) |
| Enumeration Date | 2024-03-20 |
| Last Update Date | 2024-09-04 |