Provider Demographics
NPI:1396231924
Name:WALLACE, LORI ANN (LPN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-1100
Mailing Address - Country:US
Mailing Address - Phone:937-844-8186
Mailing Address - Fax:
Practice Address - Street 1:116 W COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-1100
Practice Address - Country:US
Practice Address - Phone:937-844-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN113993164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse