Provider Demographics
NPI:1073359592
Name:WALLACE, REGINA SUE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:SUE
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 1:7468 CABWAYLINGO PARK RD
Mailing Address - Street 2:
Mailing Address - City:WILSONDALE
Mailing Address - State:WV
Mailing Address - Zip Code:25699-8021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7468 CABWAYLINGO PARK RD
Practice Address - Street 2:
Practice Address - City:WILSONDALE
Practice Address - State:WV
Practice Address - Zip Code:25699-8021
Practice Address - Country:US
Practice Address - Phone:304-733-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant