Colleen Wallace
Individual provider Active NPI Adult Medicine Physician · Umatilla, FL
NPI 1992394423 · NPPES record last updated Jan 21, 2021
Key facts
- NPI
- 1992394423
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Adult Medicine Physician 207QA0505X
- License
- 11011114 (FL)
- Practice address
- 287 S Central Ave
Umatilla, FL 32784-8411 - Phone
- (352) 747-0747
- NPI assigned
- Jan 11, 2021
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2020
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
Practice addresses (Care Compare)
287 S Central Ave
Umatilla, FL 32784-8411
Phone (352) 747-0747
Hospital & facility affiliations
- Pinnacle Home Care of the Villages Inc
- Adventhealth Waterman
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210216001905 | FL | Practitioner - Nurse Practitioner | 0749695286 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11011114 | FL | MD | Adult Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wallace Health, LLC | Current |
Accepting new patients |
Locations
287 S Central Ave
Umatilla, FL 32784
Phone (352) 669-3161
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Medicine Physician | 207QA0505X | 11011114 | FL | Yes |
Addresses
Primary practice location
287 S Central Ave
Umatilla, FL 32784-8411
Mailing address
PO Box 2485
Umatilla, FL 32784-2485
Phone (352) 551-9404
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Other URL | wallacehealthcares4u@gmail.com | Direct |
Other providers in Umatilla, FL
- Umatilla Optical & Hearing Aid Center Inc
- Umatilla Optical and Hearing Aid Center, Inc
- Umatilla Pharmacy Inc
- Jordan Andrew Walker
- Wallace Health, LLC
- Michele L Walsh
- Briana Whitsitt
- Stephenie Jo Wolford-Ward
- Veronica C Wright
All providers in Umatilla, FL · Adult Medicine Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 21, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.