Provider Demographics
NPI:1043673643
Name:WALLACE, AMBER LEIGH (LPN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:LEIGH
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:113 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1077
Mailing Address - Country:US
Mailing Address - Phone:231-220-4620
Mailing Address - Fax:
Practice Address - Street 1:113 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1077
Practice Address - Country:US
Practice Address - Phone:231-220-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108739164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse