Provider Demographics
NPI:1619740941
Name:WALLACE, VICTORIA CATHERINE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:CATHERINE
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 1:12000 GIDDINGS WAY APT 12205
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4640
Mailing Address - Country:US
Mailing Address - Phone:843-593-1582
Mailing Address - Fax:
Practice Address - Street 1:171 CHURCH ST STE 140
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-3136
Practice Address - Country:US
Practice Address - Phone:843-593-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide