Kisha Wallace

Primary specialty

Adult Health Nurse PractitionerTaxonomy code 363LA2200X

License

F308252 Issued in NY

Practice address

1 Gustave L Levy PL
New York, NY 10029-6504

Phone

(212) 241-6500

Fax

(212) 426-5040

NPI assigned

Jul 17, 2018

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

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Icahn School of Medicine at Mount Sinai

  • Geriatric Medicine (Internal Medicine) Physician
  • New York, NY
  • NPI 1689947160
  Medicare reassignment NPD
• Icahn School of Medicine at Mount Sinai

  • Eyewear Supplier
  • New York, NY
  • NPI 1760227466
  NPD

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

{
    "created_epoch": "1531785600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623196800000",
    "number": "1417433939",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 E 42ND ST # 3000",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100175612",
            "telephone_number": "646-605-8119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 GUSTAVE L LEVY PL",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100296504",
            "telephone_number": "212-241-6500",
            "fax_number": "212-426-5040"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "320 Wilson St",
            "address_purpose": "LOCATION",
            "city": "West Hempstead",
            "state": "NY",
            "postal_code": "115522019",
            "country_code": "US",
            "telephone_number": "516-485-5864",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KISHA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-07-17",
        "last_updated": "2021-06-09",
        "certification_date": "2021-06-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LA2200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Adult Health",
            "state": "NY",
            "license": "F308252",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Brynn Wallace, LCSW
• Chantay Wallace
• Charles Jerome Wallace, CASAC-T
• David Wallace
• Kathleen Wallace
• Kyana Wallace, PA-C
• Laney Elizabeth Wallace, MPS, LCAT, ATR-BC
• Lauren Wallace
• Loretta Wallace
• Mario James Wallace, PT, DPT

• Adult Health Nurse Practitioner in New York, NY
• Providers in New York, NY by specialty
• Adult Health Nurse Practitioner in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.