Provider Demographics
NPI:1508294133
Name:WALLACE-SCOTT, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:WALLACE-SCOTT
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 1:198 E 96TH ST
Mailing Address - Street 2:APT#2R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-2845
Mailing Address - Country:US
Mailing Address - Phone:347-825-4056
Mailing Address - Fax:
Practice Address - Street 1:198 E 96TH ST
Practice Address - Street 2:APT#2R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-2845
Practice Address - Country:US
Practice Address - Phone:347-825-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285924164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse