Provider Demographics
NPI:1831427533
Name:WALLACE, PORTIA DIONNE
Entity type:Individual
Prefix:MISS
First Name:PORTIA
Middle Name:DIONNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 SOUTH BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2673
Mailing Address - Country:US
Mailing Address - Phone:704-506-2315
Mailing Address - Fax:
Practice Address - Street 1:7800 TRAVERS RUN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-6504
Practice Address - Country:US
Practice Address - Phone:704-506-2315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health