Provider Demographics
NPI:1619353224
Name:WALLACE, LETITIA J (RN)
Entity Type:Individual
Prefix:MRS
First Name:LETITIA
Middle Name:J
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 1:20 W BANK ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3279
Mailing Address - Country:US
Mailing Address - Phone:804-862-8002
Mailing Address - Fax:804-862-8023
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-862-8002
Practice Address - Fax:804-862-8023
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001236086163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse