Provider Demographics
NPI:1265529937
Name:WALLACE, MELODY ELIZABETH (RN, BSN)
Entity type:Individual
Prefix:MS
First Name:MELODY
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:MS
Other - First Name:MELODY
Other - Middle Name:ELIZABETH
Other - Last Name:JOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:2625 ANITA
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041
Mailing Address - Country:US
Mailing Address - Phone:972-926-2671
Mailing Address - Fax:972-926-2679
Practice Address - Street 1:2625 ANITA DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041
Practice Address - Country:US
Practice Address - Phone:972-926-2671
Practice Address - Fax:972-926-2679
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0058400601163W00000X
TX163431163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse