Provider Demographics
NPI:1578317095
Name:WALLACE, NAKKIA (RN)
Entity Type:Individual
Prefix:
First Name:NAKKIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5247 N RIVER BLVD NE APT 8
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52411-7883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2209
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA169565163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical