Provider Demographics
NPI:1093488728
Name:WALLACE, MICHELE R (CNA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:COTTRELLVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48039-3210
Mailing Address - Country:US
Mailing Address - Phone:586-339-7930
Mailing Address - Fax:
Practice Address - Street 1:7770 MARSH RD
Practice Address - Street 2:
Practice Address - City:COTTRELLVILLE
Practice Address - State:MI
Practice Address - Zip Code:48039-3210
Practice Address - Country:US
Practice Address - Phone:586-339-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI000061844376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI000061844OtherCNA CERTIFICATION NUMBER