Provider Demographics
NPI:1821598707
Name:WALLACE, BEAUTY
Entity Type:Individual
Prefix:
First Name:BEAUTY
Middle Name:
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 1:434 EULESS DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:434 EULESS DR
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3189
Practice Address - Country:US
Practice Address - Phone:214-317-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668567163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX668567OtherTEXAS BOARD OF NURSING
TX668567OtherTEXAS BON