Zandra Wynette Wallace

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

Practice address

20316 Natures Corner Dr
Tampa, FL 33647-3580

Phone

(813) 575-8108

NPI assigned

Jan 26, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1643155200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643155200000",
    "number": "1053063412",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20316 NATURES CORNER DR",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336473580",
            "telephone_number": "813-575-8108"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20316 NATURES CORNER DR",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336473580",
            "telephone_number": "813-575-8108"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ZANDRA",
        "middle_name": "WYNETTE",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-01-26",
        "last_updated": "2022-01-26",
        "certification_date": "2022-01-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "FL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peggy Lynn Wallace, ARNP
• Sergio Wallace
• Skye Wallace, M.S. CCC-SLP
• Tiaja Wallace
• Yelda N Wallace
• Maria Wallen
• Marva Ann Marie Wallen, RN
• Seren Devol Wallen, PA-C
• Jennifer Lynn Waller, APRN
• Kenneth Ray Waller Jr., RBT

• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Tampa, FL
• Providers in Tampa, FL by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.