Debra Ann Wallace, FNP

Primary specialty

Plastic and Reconstructive Surgery PhysicianTaxonomy code 2086S0122X

License

8326 Issued in CA

Practice address

1100 N State Street
Clinic Tower A6A231A
Los Angeles, CA 90033

Phone

(323) 409-7788

Fax

(323) 441-7298

NPI assigned

Jul 24, 2017

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

State licenses

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

{
    "created_epoch": "1500854400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1529107200000",
    "number": "1770006538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4632 E VILLAGE RD",
            "city": "LONG BEACH",
            "state": "CA",
            "postal_code": "908081545",
            "telephone_number": "323-409-7788",
            "fax_number": "323-441-7298"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 N STATE STREET",
            "address_2": "CLINIC TOWER A6A231A",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "90033",
            "telephone_number": "323-409-7788",
            "fax_number": "323-441-7298"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DEBRA",
        "middle_name": "ANN",
        "name_prefix": "Mrs.",
        "credential": "FNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-07-24",
        "last_updated": "2018-06-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2086S0122X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": "CA",
            "license": "8326",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Caroline Sheridan Wallace, AMFT
• Cheyenne Wallace
• David Wallace
• David S. Wallace, LMFT
• De Voria Wallace
• Dejuanna Wallace
• Emma Wallace
• Gunseli Wallace
• Hannah Wallace, MD, MPH
• Jamaal Aqeel Wallace

• Plastic and Reconstructive Surgery Physician in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Plastic and Reconstructive Surgery Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2018; 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.