Provider Demographics
NPI:1245350172
Name:WALLACE, SANDRA V (RN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:V
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 1:1628 ORIOLE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6127
Mailing Address - Country:US
Mailing Address - Phone:405-321-7610
Mailing Address - Fax:
Practice Address - Street 1:909 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5229
Practice Address - Country:US
Practice Address - Phone:405-573-3909
Practice Address - Fax:405-573-3966
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0047895 D6361633163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult