Provider Demographics
NPI:1043556483
Name:WALLACE, VALERIE
Entity Type:Individual
Prefix:MS
First Name:VALERIE
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 1:61 EAST SENNEBEC RD.
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:ME
Mailing Address - Zip Code:04862-4616
Mailing Address - Country:US
Mailing Address - Phone:207-785-2744
Mailing Address - Fax:
Practice Address - Street 1:61 EAST SENNEBEC ROAD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:ME
Practice Address - Zip Code:04862-4616
Practice Address - Country:US
Practice Address - Phone:207-785-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker