Provider Demographics
NPI:1922653237
Name:WALLACE, ANN MARIE
Entity Type:Individual
Prefix:MRS
First Name:ANN MARIE
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 1:22 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4012
Mailing Address - Country:US
Mailing Address - Phone:917-652-1561
Mailing Address - Fax:
Practice Address - Street 1:22 HICKORY ST
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-4012
Practice Address - Country:US
Practice Address - Phone:917-652-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty