Provider Demographics
NPI:1154409357
Name:WALLIS, NICOLE LYNN (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1505
Mailing Address - Country:US
Mailing Address - Phone:740-384-4341
Mailing Address - Fax:
Practice Address - Street 1:421 EAST 1ST STREET
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692
Practice Address - Country:US
Practice Address - Phone:740-384-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103921164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse