Provider Demographics
NPI:1104657352
Name:WALLACE, ANGELA
Entity type:Individual
Prefix:MS
First Name:ANGELA
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:PO BOX 450170
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77245-0170
Mailing Address - Country:US
Mailing Address - Phone:281-464-6648
Mailing Address - Fax:
Practice Address - Street 1:10707 CORPORATE DR STE 250-103
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-4095
Practice Address - Country:US
Practice Address - Phone:281-464-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant