Provider Demographics
NPI:1033874862
Name:WALLACE, EKUA
Entity Type:Individual
Prefix:
First Name:EKUA
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 1:6558 WESTMINSTER CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8793
Mailing Address - Country:US
Mailing Address - Phone:513-372-2629
Mailing Address - Fax:
Practice Address - Street 1:6558 WESTMINSTER CT
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-8793
Practice Address - Country:US
Practice Address - Phone:513-372-2629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.461578163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health