Nicole Wallace, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA9103316 Issued in FL

Practice address

1324 Lakeland Hills Blvd
Lakeland, FL 33805-4543

Phone

(863) 687-1132

Fax

(863) 687-1439

NPI assigned

Jul 25, 2006

Sex

Female

Sole proprietor

No

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 FL

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

Merit-based Incentive Payment System (MIPS)

Final score

100 of 100Reported as group

Promoting interoperability

98

Improvement activities

40

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

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.

• Emergency Physicians Inc

  • Emergency Medicine Physician
  • Jacksonville, FL
  • NPI 1285686675
  Medicare reassignment
• Emergency Physicians Inc

  • Emergency Medicine Physician
  • Brunswick, GA
  • NPI 1477001972
  NPD
• Florida Em-I Medical Services PA

  • Emergency Medicine Physician
  • Lakeland, FL
  • NPI 1871542720
  NPD (past)

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

{
    "created_epoch": "1153785600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1273017600000",
    "number": "1508889254",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5026 FAIRFAX DR",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338132917",
            "telephone_number": "863-644-2455",
            "fax_number": "727-507-3618"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1324 LAKELAND HILLS BLVD",
            "city": "LAKELAND",
            "state": "FL",
            "postal_code": "338054543",
            "telephone_number": "863-687-1132",
            "fax_number": "863-687-1439"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "NICOLE",
        "name_prefix": "Mrs.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-25",
        "last_updated": "2010-05-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9103316",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tierra Shenae Walker, CNA
• Rachel Anne Wall, MD
• Ward B. Wall Jr., M.D.
• Kiblena Wallace, BCBA
• Melissa Emily Wallace, LCSW
• Shannon Wallace, HOME HEATH AIDE
• Rebecca Waller-Ellison, MA
• Izella Walls
• Rosemary Walls
• Dylan Jarod Walter, MD

• Physician Assistant in Lakeland, FL
• Providers in Lakeland, FL by specialty
• Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2010; 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.