Active NPI
Benjamin Levi Wallace, FNP-C
- Family Nurse Practitioner
- Huntsville, TX
National Provider Identifier
1962913293
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Nurse Practitioner
- License
- AP134640
- Practice address
- 264 FM 3478 Rd
Huntsville, TX 77320-3322 - Phone
- (936) 291-4200
- NPI assigned
- Oct 13, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | AP134640 | TX | Primary |
Addresses
Primary practice location
264 FM 3478 Rd
Huntsville, TX 77320-3322
Mailing address
540 Pine St
Crockett, TX 75835-5555
Phone (936) 222-1358
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
| License | State | Type | Specialty |
|---|---|---|---|
| AP134640 | TX | MD | Family Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1507852800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1507852800000",
"number": "1962913293",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "540 PINE ST",
"city": "CROCKETT",
"state": "TX",
"postal_code": "758355555",
"telephone_number": "936-222-1358"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "264 FM 3478 RD",
"city": "HUNTSVILLE",
"state": "TX",
"postal_code": "773203322",
"telephone_number": "936-291-4200"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "BENJAMIN",
"middle_name": "LEVI",
"name_prefix": "Mr.",
"credential": "FNP-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-10-13",
"last_updated": "2017-10-13",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "TX",
"license": "AP134640",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Huntsville, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.