Provider Demographics
NPI:1376028712
Name:WALLACE, TWANNA LENITA
Entity Type:Individual
Prefix:
First Name:TWANNA
Middle Name:LENITA
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 1:4083 JOHN I HAY RD
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-9361
Mailing Address - Country:US
Mailing Address - Phone:601-500-0027
Mailing Address - Fax:601-277-4039
Practice Address - Street 1:321 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2113
Practice Address - Country:US
Practice Address - Phone:601-500-0027
Practice Address - Fax:601-277-4039
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health