Provider Demographics
NPI:1598884272
Name:WALLACE, MICHELLE MARIE I (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:WALLACE
Suffix:I
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 1:17887 STATE ROUTE 58
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9464
Mailing Address - Country:US
Mailing Address - Phone:440-864-3984
Mailing Address - Fax:440-774-2184
Practice Address - Street 1:17887 STATE ROUTE 58
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090-9464
Practice Address - Country:US
Practice Address - Phone:440-864-3984
Practice Address - Fax:440-774-2184
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH295117163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2259041Medicaid