| Doctor Name: | MS. SUSAN ANN WALLACE |
| NPI Number: | 1104000199 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | ARNP3262052 |
| Business Practice Address: | 17501 Dale Mabry Hwy N Lutz, FL - 335484521 |
| Business Phone Number: | 8139621000 |
| Business Fax Number: | |
| Mailing Address: | 17501 Dale Mabry Hwy N, LUTZ |
| State: | FL |
| Postal Code: | 335484521 |
| Phone Number: | 8139621000 |
| Fax Number: | |
| NPI Enumeration Date: | 12/26/2007 |
| NPI Last Update Date: | 12/26/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | ARNP3262052 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |