Provider Demographics
NPI:1831987627
Name:FERRELL, WALLACE JR
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:FERRELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 BREEDEN CRK
Mailing Address - Street 2:
Mailing Address - City:BREEDEN
Mailing Address - State:WV
Mailing Address - Zip Code:25666-6601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6809 BREEDEN CRK
Practice Address - Street 2:
Practice Address - City:BREEDEN
Practice Address - State:WV
Practice Address - Zip Code:25666-6601
Practice Address - Country:US
Practice Address - Phone:304-733-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant