Provider Demographics
NPI:1457660508
Name:WALLACE, SARAH (BSN, RN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1485
Mailing Address - Country:US
Mailing Address - Phone:712-255-8901
Mailing Address - Fax:712-255-9161
Practice Address - Street 1:1125 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1485
Practice Address - Country:US
Practice Address - Phone:712-255-8901
Practice Address - Fax:712-255-9161
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA117797163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse