Provider Demographics
NPI:1710194402
Name:WALLACE, LOLITA LASHELL (MED ASST HHA STNA)
Entity Type:Individual
Prefix:MS
First Name:LOLITA
Middle Name:LASHELL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED ASST HHA STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6748 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1828
Mailing Address - Country:US
Mailing Address - Phone:216-323-1877
Mailing Address - Fax:
Practice Address - Street 1:6748 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1828
Practice Address - Country:US
Practice Address - Phone:216-323-1877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH269385Medicaid
OHT1019Medicaid