Provider Demographics
NPI:1598359911
Name:WALLACE, ELIZABETH A
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
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 1:125 N COLLISON AVE
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:NM
Mailing Address - Zip Code:87714-8505
Mailing Address - Country:US
Mailing Address - Phone:575-770-1700
Mailing Address - Fax:575-376-2442
Practice Address - Street 1:125 N COLLISON AVE
Practice Address - Street 2:
Practice Address - City:CIMARRON
Practice Address - State:NM
Practice Address - Zip Code:87714-8505
Practice Address - Country:US
Practice Address - Phone:575-377-6991
Practice Address - Fax:575-376-2442
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM402513163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty