Provider Demographics
NPI:1609276344
Name:WALLACE, PEGGY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4902
Mailing Address - Country:US
Mailing Address - Phone:480-334-5385
Mailing Address - Fax:
Practice Address - Street 1:7428 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4902
Practice Address - Country:US
Practice Address - Phone:480-334-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ031264164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse