Provider Demographics
NPI:1649047069
Name:WALLACE, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-2036
Mailing Address - Country:US
Mailing Address - Phone:267-280-2619
Mailing Address - Fax:
Practice Address - Street 1:320 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:CHELTENHAM
Practice Address - State:PA
Practice Address - Zip Code:19012-2036
Practice Address - Country:US
Practice Address - Phone:267-280-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA71193601372500000X, 376J00000X, 385H00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care