Provider Demographics
NPI:1770750002
Name:WALLACE, CASSANDRA (LPTN)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPTN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5441
Mailing Address - Country:US
Mailing Address - Phone:501-686-9393
Mailing Address - Fax:
Practice Address - Street 1:4601 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5441
Practice Address - Country:US
Practice Address - Phone:501-686-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1658167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician