Provider Demographics
NPI:1669717211
Name:WALLACE, NANCY ANN (COTA)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7548
Mailing Address - Country:US
Mailing Address - Phone:601-624-2618
Mailing Address - Fax:
Practice Address - Street 1:2909 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-7548
Practice Address - Country:US
Practice Address - Phone:601-624-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT1220224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194418721Medicaid