Provider Demographics
NPI:1164796520
Name:WALLACE, HATTIE
Entity Type:Individual
Prefix:
First Name:HATTIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HATTIE
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:14625 S MOUNTAIN PKWY
Mailing Address - Street 2:APT 1056
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7142
Mailing Address - Country:US
Mailing Address - Phone:602-565-2159
Mailing Address - Fax:
Practice Address - Street 1:14625 S MOUNTAIN PKWY
Practice Address - Street 2:APT 1056
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7142
Practice Address - Country:US
Practice Address - Phone:602-565-2159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP044351164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse