Provider Demographics
NPI:1508540873
Name:WALLACE, ANNMARIE L
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:L
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 1:549 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-2221
Mailing Address - Country:US
Mailing Address - Phone:260-312-2588
Mailing Address - Fax:
Practice Address - Street 1:549 E 5TH ST
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2221
Practice Address - Country:US
Practice Address - Phone:260-312-2588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant