Provider Demographics
NPI:1154960177
Name:WALLACE, SAMARA KACHE
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:KACHE
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 1:634 CAPITOL HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-2901
Mailing Address - Country:US
Mailing Address - Phone:202-839-6862
Mailing Address - Fax:
Practice Address - Street 1:634 CAPITOL HEIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-2901
Practice Address - Country:US
Practice Address - Phone:202-839-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant