Provider Demographics
NPI:1861663122
Name:WALLACE, AMY BETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
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 1:150 GATE HOUSE TRL
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9559
Mailing Address - Country:US
Mailing Address - Phone:585-359-3557
Mailing Address - Fax:
Practice Address - Street 1:150 GATE HOUSE TRL
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9559
Practice Address - Country:US
Practice Address - Phone:585-359-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276860164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570267Medicaid