Provider Demographics
NPI:1922835206
Name:WALLACE, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 RICH CREEK VALLEY RD LOT 20
Mailing Address - Street 2:
Mailing Address - City:PETERSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:24963-8717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:742 RICH CREEK VALLEY RD LOT 20
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963-8717
Practice Address - Country:US
Practice Address - Phone:304-994-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide