Provider Demographics
NPI:1063947018
Name:WALLACE, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:2201 1/2 ROSLYN AVE
Mailing Address - Street 2:APT 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2522
Mailing Address - Country:US
Mailing Address - Phone:443-468-2142
Mailing Address - Fax:
Practice Address - Street 1:2201 1/2 ROSLYN AVE
Practice Address - Street 2:APT 203
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2522
Practice Address - Country:US
Practice Address - Phone:443-468-2142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide