NPIMap

Individual provider Active NPI

Debra Ann Wallace

  • Nurse's Aide
  • Tampa, FL
National Provider Identifier
1912149188
Registry record updated Apr 2, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse's AideTaxonomy code 376K00000X
License
CNA 54979 Issued in FL
Practice address
5608 Kenny Dr
Tampa, FL 33617-7711
Phone
(813) 546-4884
Fax
(813) 983-1860
NPI assigned
Apr 2, 2009
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 2, 2009

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

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Attendant Care Provider 3747A0650X 684206296 FL
Personal Care Attendant 3747P1801X 684206296 FL
Nurse's Aide 376K00000X CNA 54979 FL Primary
Adult Companion 372600000X 684206296 FL

Addresses

Primary practice location

5608 Kenny Dr
Tampa, FL 33617-7711

Mailing address

5608 Kenny Dr
Tampa, FL 33617-7711
Phone (813) 546-4884

Other identifiers 3

IdentifierTypeStateIssuer
14627300MedicaidFL
CNA54979OtherFLCNA
684206296MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
684206296FLMDAttendant Care Provider
CNA 54979FLMDNurse's Aide

Practice roles

OrganizationSpecialtyStatusNew patients
Debra'S Divine Care Inc Past Accepting new patients
Debra'S Divine Care LLC Past Accepting new patients

Organizations & group practices 2

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.

NPI Registry JSON

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

{
    "created_epoch": "1238630400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1238630400000",
    "number": "1912149188",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5608 KENNY DR",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336177711",
            "telephone_number": "813-546-4884",
            "fax_number": "813-983-1860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5608 KENNY DR",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336177711",
            "telephone_number": "813-546-4884",
            "fax_number": "813-983-1860"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "DEBRA",
        "middle_name": "ANN",
        "name_prefix": "Mrs.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2009-04-02",
        "last_updated": "2009-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "3747A0650X",
            "taxonomy_group": "",
            "desc": "Technician, Attendant Care Provider",
            "state": "FL",
            "license": "684206296",
            "primary": false
        },
        {
            "code": "3747P1801X",
            "taxonomy_group": "",
            "desc": "Technician, Personal Care Attendant",
            "state": "FL",
            "license": "684206296",
            "primary": false
        },
        {
            "code": "376K00000X",
            "taxonomy_group": "",
            "desc": "Nurse's Aide",
            "state": "FL",
            "license": "CNA 54979",
            "primary": true
        },
        {
            "code": "372600000X",
            "taxonomy_group": "",
            "desc": "Adult Companion",
            "state": "FL",
            "license": "684206296",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "14627300",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CNA",
            "identifier": "CNA54979",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "684206296",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tampa, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2009; 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.