Provider Demographics
NPI:1881801090
Name:WALLACE, KATHLEEN NICOLE (BSE)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BSE
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:NICOLE
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 WESTERN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-9137
Mailing Address - Country:US
Mailing Address - Phone:870-245-7714
Mailing Address - Fax:
Practice Address - Street 1:2410 PINE ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4335
Practice Address - Country:US
Practice Address - Phone:870-245-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist