Provider Demographics
NPI:1366258337
Name:WALLACE, ANGELA (RN, SANE)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, SANE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 OLD BOONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-9207
Mailing Address - Country:US
Mailing Address - Phone:859-779-8291
Mailing Address - Fax:
Practice Address - Street 1:3020 OLD BOONESBORO RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-9207
Practice Address - Country:US
Practice Address - Phone:859-779-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1096760163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator