Provider Demographics
NPI:1093166852
Name:WALLACE, VALERIE
Entity Type:Individual
Prefix:
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 1:13401 OLD MCCOLL RD
Mailing Address - Street 2:
Mailing Address - City:GIBSON
Mailing Address - State:NC
Mailing Address - Zip Code:28343-8541
Mailing Address - Country:US
Mailing Address - Phone:910-544-9103
Mailing Address - Fax:910-506-3532
Practice Address - Street 1:833 REDDEN ROW
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7221
Practice Address - Country:US
Practice Address - Phone:910-544-9103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007229437343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)