Provider Demographics
NPI:1134688864
Name:WALLACE, KECHA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KECHA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3319
Mailing Address - Country:US
Mailing Address - Phone:608-234-0265
Mailing Address - Fax:
Practice Address - Street 1:885 ROBIN DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3319
Practice Address - Country:US
Practice Address - Phone:608-234-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI229385-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse