Provider Demographics
NPI:1053144378
Name:WALLACE, ANGEL DIANE
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:DIANE
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 1:366 SUZANNE DR
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-1932
Mailing Address - Country:US
Mailing Address - Phone:270-784-0144
Mailing Address - Fax:
Practice Address - Street 1:366 SUZANNE DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-1932
Practice Address - Country:US
Practice Address - Phone:270-784-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist