Provider Demographics
NPI:1629367990
Name:WALLACE, PAMELA YVETTE (LPN)
Entity type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:YVETTE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 DELAWARE AVE
Mailing Address - Street 2:SUITE 310 INTERIM HEALTHCARE
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1620
Mailing Address - Country:US
Mailing Address - Phone:716-852-5900
Mailing Address - Fax:716-852-5913
Practice Address - Street 1:360 DELAWARE AVE
Practice Address - Street 2:SUITE 310 INTERIM HEALTHCARE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1620
Practice Address - Country:US
Practice Address - Phone:716-852-5900
Practice Address - Fax:716-852-5913
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266271-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse