Provider Demographics
NPI:1811434400
Name:WALLACE, RICHARD (RN BSN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 HACKAMORE DR N
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-2632
Mailing Address - Country:US
Mailing Address - Phone:719-252-6631
Mailing Address - Fax:
Practice Address - Street 1:4905 HACKAMORE DR N
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-2632
Practice Address - Country:US
Practice Address - Phone:719-252-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO112239163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse