Provider Demographics
NPI:1114746625
Name:WALLACE, LINDSAY NICOLE
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:NICOLE
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 1:5408 MORNING GLORY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43103-3518
Mailing Address - Country:US
Mailing Address - Phone:276-739-8755
Mailing Address - Fax:
Practice Address - Street 1:5408 MORNING GLORY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMFIELD
Practice Address - State:OH
Practice Address - Zip Code:43103-3518
Practice Address - Country:US
Practice Address - Phone:276-739-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker