| National Provider Identifier [NPI]: | 1215981170 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | JESSICA |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | NURSE PRACTITIONER |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10833 LE CONTE AVE |
| Street Address 2 Of The Provider | CHS BL- 731C |
| City Of The Provider | LOS ANGELES |
| Zip Code Of The Provider | 900953075 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 8 |
| Number Of Services | 176 |
| Number Of Medicare Beneficiaries | 104 |
| Total Submitted Charge Amount | 208073 |
| Total Medicare Allowed Amount | 17534.5 |
| Total Medicare Payment Amount | 13682.86 |
| Total Medicare Standardized Payment Amount | 15027.99 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 8 |
| Number Of Medical Services | 176 |
| Number Of Medicare Beneficiaries With Medical Services | 104 |
| Total Medical Submitted Charge Amount | 208073 |
| Total Medical Medicare Allowed Amount | 17534.5 |
| Total Medical Medicare Payment Amount | 13682.86 |
| Total Medical Medicare Standardized Payment Amount | 15027.99 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 45 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 51 |
| Number Of Male Beneficiaries | 53 |
| Number Of Non Hispanic White Beneficiaries | 60 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 15 |
| Number Of Hispanic Beneficiaries | 18 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 60 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 44 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 42 |
| Percent Of With Chronic Kidney Disease | 75 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 42 |
| Percent Of With Diabetes | 51 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 47 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 3.6114 |