Provider Demographics
NPI:1841211273
Name:WALLACE, KAY (CRNA)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18736
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07191-8736
Mailing Address - Country:US
Mailing Address - Phone:800-426-1699
Mailing Address - Fax:
Practice Address - Street 1:601 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08629-1915
Practice Address - Country:US
Practice Address - Phone:609-599-5097
Practice Address - Fax:609-599-6312
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR03239800163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ021767MJZMedicare ID - Type Unspecified