Provider Demographics
NPI:1295769859
Name:WALLACE, VICTORIA ANNE (ANP)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 EAGAN AVE
Mailing Address - Street 2:FAIRBANKS CORRECTIONAL CENTER
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5703
Mailing Address - Country:US
Mailing Address - Phone:907-458-6700
Mailing Address - Fax:
Practice Address - Street 1:1931 EAGAN AVE
Practice Address - Street 2:FAIRBANKS CORRECTIONAL CENTER
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5703
Practice Address - Country:US
Practice Address - Phone:907-458-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0254Medicaid
AKNP02541Medicaid
AKNP02541Medicaid
AKNP0254Medicaid
AK0361450001Medicare NSC
160338Medicare PIN
AKNP02541Medicaid
AKK162330Medicare PIN