Provider Demographics
NPI:1386202125
Name:WALLACE, SASHA LEE B
Entity Type:Individual
Prefix:
First Name:SASHA LEE
Middle Name:B
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 1:6412 N UNIVERSITY DR STE 114
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6412 N UNIVERSITY DR STE 114
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4002
Practice Address - Country:US
Practice Address - Phone:954-726-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty