Provider Demographics
NPI:1790436046
Name:WALLACE, YOLALNDA N/A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:YOLALNDA
Middle Name:N/A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:YOLANDA
Other - Middle Name:
Other - Last Name:LIPSCOMB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:8500 BROADWAY STE H
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7006
Mailing Address - Country:US
Mailing Address - Phone:219-769-7710
Mailing Address - Fax:219-769-7758
Practice Address - Street 1:8500 BROADWAY STE H
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7006
Practice Address - Country:US
Practice Address - Phone:219-769-7710
Practice Address - Fax:219-769-7758
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27068803A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse