Provider Demographics
NPI:1881738789
Name:WALLACE, TERRI ANN (RN)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:ANN
Other - Last Name:BOOTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 TYRE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:925 BEAR CORBITT RD
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1323
Practice Address - Country:US
Practice Address - Phone:302-454-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL10021724163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool