Provider Demographics
NPI:1164006813
Name:WALLACE, CHIQUITA
Entity Type:Individual
Prefix:
First Name:CHIQUITA
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 1:5715 LANTANA AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-3013
Mailing Address - Country:US
Mailing Address - Phone:513-541-3712
Mailing Address - Fax:
Practice Address - Street 1:5715 LANTANA AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-3013
Practice Address - Country:US
Practice Address - Phone:513-541-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No347C00000XTransportation ServicesPrivate Vehicle
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)