Provider Demographics
NPI:1154156586
Name:WALLACE, ALISHA ROSE (RN)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:ROSE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BLACK HUT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02830-1240
Mailing Address - Country:US
Mailing Address - Phone:339-237-2784
Mailing Address - Fax:
Practice Address - Street 1:210 BLACK HUT RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:RI
Practice Address - Zip Code:02830-1240
Practice Address - Country:US
Practice Address - Phone:339-237-2784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2314105163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health