License Verification

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NICOLE ELIZABETH WALLACE

License Number: PA9103316

Data As Of 5/19/2024

Profession
Physician Assistant
License
PA9103316
License Status
CLEAR/Active
Qualifications
Prescribing
License Expiration Date
1/31/2026
License Original Issue Date
06/20/2005
Address of Record
1324 LAKELAND HILLS BLVD
LAKELAND REGIONAL MEDICAL CENTER
EMERGENCY DEPARTMENT
LAKELAND, FL 33805
Controlled Substance Prescriber (for the Treatment of Chronic Non-malignant Pain)
No
Discipline on File
No
Public Complaint
No

No secondary locations found.


Name Relationship Profession License Effective Date
ABRAHAMSEN, NADIA Supervising Prescribing Practitioner Medical Doctor 108847 03/02/2018
ANCHETA, JOEY SALDANA MD Supervising Prescribing Practitioner Medical Doctor 72598 07/13/2017
BRENNER, ANNETTE MAGNANT Supervising Prescribing Practitioner Medical Doctor 70818 02/06/2020
BROWN, RICHARD Supervising Prescribing Practitioner Medical Doctor 132286 09/14/2017
CAUSEY, ALAN LANE Supervising Prescribing Practitioner Medical Doctor 70284 12/28/2015
COVITZ, SHANNON MIXON Supervising Prescribing Practitioner Osteopathic Physician 11652 02/06/2020
DUBEY, JESSE VINCENT Supervising Prescribing Practitioner Osteopathic Physician 13099 09/01/2018
GLUECK, JESSE Supervising Prescribing Practitioner Medical Doctor 136392 08/04/2020
JOHN, TESHY VARUGHESE Supervising Prescribing Practitioner Medical Doctor 125364 12/01/2018
LALANI, FARAH NAUSHIR Supervising Prescribing Practitioner Osteopathic Physician 10814 12/28/2015
LONGO, JENNIFER ANN Supervising Prescribing Practitioner Medical Doctor 113332 11/05/2019
MEMON, SUMERA HAROON Supervising Prescribing Practitioner Osteopathic Physician 11668 08/20/2018
MISDARY, JOHN SARATIAL MD Supervising Prescribing Practitioner Medical Doctor 111957 03/28/2018
PALIGA, ANDREW Supervising Prescribing Practitioner Medical Doctor 111562 05/06/2019
PATEL, TEJAS Supervising Prescribing Practitioner Osteopathic Physician 13790 05/06/2019
PAYOR, AUSTIN DANIEL Supervising Prescribing Practitioner Osteopathic Physician 10925 04/14/2020
REINHARDT, NEIL CHRISTOPHER Supervising Prescribing Practitioner Medical Doctor 69496 11/05/2019
SPENCER, ANDREW JOSEPH Supervising Prescribing Practitioner Medical Doctor 122767 05/06/2019
SUEN, ANDREA CATHERINE Supervising Prescribing Practitioner Medical Doctor 116964 01/11/2019
TICKETT, SHELLEY SMITH Supervising Prescribing Practitioner Medical Doctor 90313 03/02/2018
VYTYKAC, ADAM Supervising Prescribing Practitioner Medical Doctor 115497 08/20/2018
WISER, ROBERT K Supervising Prescribing Practitioner Medical Doctor 139864 02/06/2020
ZACHARIAH, ANISH BABU M D Supervising Prescribing Practitioner Medical Doctor 101413 11/05/2019

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Name Relationship Profession License Effective Date

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No Continuing Education Hours Received from Approved Providers As Of 5/19/2024



* To find out more about Approved Providers, or ask a provider why the course you took is not yet listed, please visit our Continuing Education Providers page.


** Personal Development is limited to no more than 3 hours per renewal cycle. Any personal development hours in excess of this 3 hour maximum cannot be used for renewal and have been subtracted from the total available for renewal.


Please do not fax proof of Continuing Education hours to the Board Office until you have received your renewal notice in the mail.


For instructions on how to request a license certification of your Florida license to be sent to another state from the Florida Department of Health, please visit the License Certifications web page.