Provider Demographics
NPI:1326637042
Name:WALLACE, LATRICE SHEMON (RN)
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:SHEMON
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7009 N 43RD ST # 7A
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2263
Mailing Address - Country:US
Mailing Address - Phone:414-574-8984
Mailing Address - Fax:
Practice Address - Street 1:7009 N 43RD ST # 7A
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2263
Practice Address - Country:US
Practice Address - Phone:414-574-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI257195163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse