Provider Demographics
NPI:1437849411
Name:WALLACE, LEQUANA
Entity Type:Individual
Prefix:
First Name:LEQUANA
Middle Name:
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 1:352 ELMINGTON CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-6286
Mailing Address - Country:US
Mailing Address - Phone:313-737-8900
Mailing Address - Fax:734-373-0303
Practice Address - Street 1:352 ELMINGTON CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-6286
Practice Address - Country:US
Practice Address - Phone:313-737-8900
Practice Address - Fax:734-373-0303
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor