Provider Demographics
NPI:1831905579
Name:WALLACE, ORA
Entity type:Individual
Prefix:
First Name:ORA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ORA
Other - Middle Name:
Other - Last Name:JAGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:653 63RD AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-5727
Mailing Address - Country:US
Mailing Address - Phone:727-637-5874
Mailing Address - Fax:
Practice Address - Street 1:653 63RD AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-5727
Practice Address - Country:US
Practice Address - Phone:727-637-5874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy