Provider Demographics
NPI:1851142665
Name:WALLACE, JATEYA (LPN)
Entity Type:Individual
Prefix:
First Name:JATEYA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 RIDGEWICK DR
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1629
Mailing Address - Country:US
Mailing Address - Phone:440-687-7023
Mailing Address - Fax:
Practice Address - Street 1:1630 RIDGEWICK DR
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1629
Practice Address - Country:US
Practice Address - Phone:440-687-7023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH178345164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse