Provider Demographics
NPI:1659122257
Name:WALLACE, LORETTA LYNN
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:LYNN
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 1:39 MUIRWOOD GREENE DR
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-5005
Mailing Address - Country:US
Mailing Address - Phone:304-359-4017
Mailing Address - Fax:
Practice Address - Street 1:39 MUIRWOOD GREENE DR
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-5005
Practice Address - Country:US
Practice Address - Phone:304-359-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
239009053747P1801X
PA239009053747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant