Lourdes Ivette Wallace, AGACNP-BC

Primary specialty

Adult Health Nurse PractitionerTaxonomy code 363LA2200X

License

AP126548 Issued in TX

Practice address

113 Pleasant Valley Dr Ste 210
Boerne, TX 78006-5683

Phone

(830) 267-4575

Fax

(830) 267-4575

NPI assigned

Sep 18, 2014

Last updated

Sep 3, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 5

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

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, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Coe-Medical PLLC

  • Family Medicine Physician
  • Boerne, TX
  • NPI 1073907184
  Medicare reassignment NPD
• Regional Physician Services of Texas, P.a.

  • Nurse Practitioner
  • Abilene, TX
  • NPI 1043529944
  Medicare reassignment

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

{
    "created_epoch": "1410998400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1599091200000",
    "number": "1659773869",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "113 PLEASANT VALLEY DR STE 210",
            "city": "BOERNE",
            "state": "TX",
            "postal_code": "780065683",
            "telephone_number": "830-267-4575",
            "fax_number": "830-267-4575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 PLEASANT VALLEY DR STE 210",
            "city": "BOERNE",
            "state": "TX",
            "postal_code": "780065683",
            "telephone_number": "830-267-4575",
            "fax_number": "830-267-4575"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10004 Johns Rd",
            "address_purpose": "LOCATION",
            "city": "Boerne",
            "state": "TX",
            "postal_code": "780068811",
            "country_code": "US",
            "telephone_number": "830-267-4575",
            "fax_number": "830-267-4575",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "LOURDES",
        "middle_name": "IVETTE",
        "credential": "AGACNP-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-09-18",
        "last_updated": "2020-09-03",
        "certification_date": "2020-09-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "TX",
            "license": "RN860816",
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Adult Health",
            "state": "UT",
            "license": "11670071-4405",
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Adult Health",
            "state": "TX",
            "license": "AP126548",
            "primary": true
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Gerontology",
            "state": "TX",
            "license": "AP126548",
            "primary": false
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Gerontology",
            "state": "UT",
            "license": "11670071-4405",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tanya K Wainner, M.ED, M.A.
• Stephanie Ann Waite, PT
• Wal-Mart Stores Texas LLC (Walmart Pharmacy 10-1126)
• Wal-Mart Stores Texas, LP (Vision Center 30-1126)
• Walgreen Co (Walgreens #05765)
• Douglas Walls, LVN
• Kelley Ward, LPC-INTERN
• Wayne Edward Wartian
• Gayle Waterbury, LVN
• Lisa McBroom Watson, RPH

• Adult Health Nurse Practitioner in Boerne, TX
• Providers in Boerne, TX by specialty
• Adult Health Nurse Practitioner in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2020; 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.