Provider Demographics
NPI:1669154506
Name:WALLACE, GLADYS
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 BYWATER RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4402
Mailing Address - Country:US
Mailing Address - Phone:410-491-2433
Mailing Address - Fax:888-909-3217
Practice Address - Street 1:631 BYWATER RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4402
Practice Address - Country:US
Practice Address - Phone:410-491-2433
Practice Address - Fax:888-909-3217
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider