Provider Demographics
NPI:1093451122
Name:WALLACE, CATHERINE D (RN)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 MACE RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1233
Mailing Address - Country:US
Mailing Address - Phone:541-292-4552
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202005542RN163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice