Provider Demographics
NPI:1154697191
Name:WALLACE, GLORIA ELIZABEETH JR (RN)
Entity type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:ELIZABEETH
Last Name:WALLACE
Suffix:JR
Gender:F
Credentials:RN
Other - Prefix:
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Mailing Address - Street 1:141 MACON ST
Mailing Address - Street 2:RM 127
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2206
Mailing Address - Country:US
Mailing Address - Phone:718-230-9734
Mailing Address - Fax:718-230-9734
Practice Address - Street 1:141 MACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2206
Practice Address - Country:US
Practice Address - Phone:718-230-9734
Practice Address - Fax:718-230-9734
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY468506163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool