Provider Demographics
NPI:1013404813
Name:WALLACE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
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 1:1353 PERKINS DR APT C5
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-4175
Mailing Address - Country:US
Mailing Address - Phone:419-566-3757
Mailing Address - Fax:
Practice Address - Street 1:1353 PERKINS DR APT C5
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-4175
Practice Address - Country:US
Practice Address - Phone:419-566-3757
Practice Address - Fax:419-566-3757
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health