Provider Demographics
NPI:1326596321
Name:WALLACE, GISELLE TISHA (CNA)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:TISHA
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 1:5809 W RICE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651
Mailing Address - Country:US
Mailing Address - Phone:773-573-5347
Mailing Address - Fax:
Practice Address - Street 1:5809 W RICE
Practice Address - Street 2:
Practice Address - City:CHGO
Practice Address - State:IL
Practice Address - Zip Code:60651
Practice Address - Country:US
Practice Address - Phone:773-573-5347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide