Provider Demographics
NPI:1154843712
Name:WALLACE, ANNMARIE CYNTHIA
Entity type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:CYNTHIA
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 1:836 FAIROAK AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3139
Mailing Address - Country:US
Mailing Address - Phone:347-369-5492
Mailing Address - Fax:
Practice Address - Street 1:836 FAIROAK AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783
Practice Address - Country:US
Practice Address - Phone:347-369-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12922374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide