Provider Demographics
NPI:1043629124
Name:WALLACE, SARITA
Entity Type:Individual
Prefix:
First Name:SARITA
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 1:462 DOVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1167
Mailing Address - Country:US
Mailing Address - Phone:614-309-2195
Mailing Address - Fax:
Practice Address - Street 1:462 DOVERWOOD DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1167
Practice Address - Country:US
Practice Address - Phone:614-309-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
OHRN419057163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide