Provider Demographics
NPI:1417201625
Name:WALLACE, CHRISTINE ELAINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELAINE
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 1:2160 HIGHWAY 2565
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-9166
Mailing Address - Country:US
Mailing Address - Phone:410-463-3865
Mailing Address - Fax:
Practice Address - Street 1:2160 HIGHWAY 2565
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9166
Practice Address - Country:US
Practice Address - Phone:410-463-3865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH115096164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH115096OtherOHIO BOARD OF NURSING