Provider Demographics
NPI:1063617231
Name:WALLACE, BARBARA JEAN (LPN)
Entity type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:JEAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 HALL ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1522
Mailing Address - Country:US
Mailing Address - Phone:607-734-8513
Mailing Address - Fax:
Practice Address - Street 1:707 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1642
Practice Address - Country:US
Practice Address - Phone:607-732-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237963-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02680899OtherPROVIDER NUMBER