Provider Demographics
NPI:1720294572
Name:WALLACE, KATHY L (RNFA)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 STATE HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-9769
Mailing Address - Country:US
Mailing Address - Phone:573-545-4165
Mailing Address - Fax:
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO092317163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant