Provider Demographics
NPI:1902375512
Name:WALLACE, VALERIE ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 ALDER TRL
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1642
Mailing Address - Country:US
Mailing Address - Phone:434-989-2774
Mailing Address - Fax:
Practice Address - Street 1:1630 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2792
Practice Address - Country:US
Practice Address - Phone:410-604-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR192586163W00000X, 207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR192586OtherCERTIFIED REGISTERED NURSE PRACTITIONER
MDR192586OtherREGISTERED NURSE