Provider Demographics
NPI:1275346512
Name:WALLACE, BEIONKA
Entity type:Individual
Prefix:
First Name:BEIONKA
Middle Name:
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 1:2511 N 61ST ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4017
Mailing Address - Country:US
Mailing Address - Phone:531-210-8090
Mailing Address - Fax:
Practice Address - Street 1:2511 N 61ST ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4017
Practice Address - Country:US
Practice Address - Phone:531-210-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide