Provider Demographics
NPI:1801311220
Name:WALLACE, LYNNE M (RN)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BIRCH LN APT 17B
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-4302
Mailing Address - Country:US
Mailing Address - Phone:315-561-2363
Mailing Address - Fax:315-342-3810
Practice Address - Street 1:29 BIRCH LANE 17B
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-561-2363
Practice Address - Fax:315-342-3810
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY534424163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse