Provider Demographics
NPI:1073039897
Name:RAY WALLACE, BETTY
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:RAY 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 1:401 PUTNAM RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3146
Mailing Address - Country:US
Mailing Address - Phone:757-323-9485
Mailing Address - Fax:
Practice Address - Street 1:401 PUTNAM RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3146
Practice Address - Country:US
Practice Address - Phone:757-323-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver