Provider Demographics
NPI:1093205569
Name:WALLACE, DONDIRALL NICOLE
Entity Type:Individual
Prefix:
First Name:DONDIRALL
Middle Name:NICOLE
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 1:304 JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-3805
Mailing Address - Country:US
Mailing Address - Phone:682-412-2021
Mailing Address - Fax:
Practice Address - Street 1:304 JOSEPH DR
Practice Address - Street 2:
Practice Address - City:GLENN HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:75154-3805
Practice Address - Country:US
Practice Address - Phone:682-412-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227403164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse