Provider Demographics
NPI:1396723664
Name:WALLACE, MELISSA ANN (RN, CHE)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, CHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 GAFFNEY RD.
Mailing Address - Street 2:#7440 COMMANDER, USA MEDDAC-AK, ATTN: MCUC-MMD-QM
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-7440
Mailing Address - Country:US
Mailing Address - Phone:907-353-5418
Mailing Address - Fax:907-353-4845
Practice Address - Street 1:1060 GAFFNEY RD
Practice Address - Street 2:#7440 COMMANDER, USA MEDDAC-AK, ATTN: MCUC-MMD-QM
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5001
Practice Address - Country:US
Practice Address - Phone:907-353-5418
Practice Address - Fax:907-353-4845
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK18147163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse