Provider Demographics
NPI:1598259798
Name:WALLACE, FRANCENE
Entity Type:Individual
Prefix:
First Name:FRANCENE
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 1:1131 MEYER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1826
Mailing Address - Country:US
Mailing Address - Phone:314-732-9159
Mailing Address - Fax:
Practice Address - Street 1:1131 MEYER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-1826
Practice Address - Country:US
Practice Address - Phone:314-732-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care