Provider Demographics
NPI:1386163830
Name:WALLACE, DIONNE LANETTE (MSN RN CNL)
Entity type:Individual
Prefix:MRS
First Name:DIONNE
Middle Name:LANETTE
Last Name:WALLACE
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Gender:F
Credentials:MSN RN CNL
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Mailing Address - Street 1:15730 MOK AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2367
Mailing Address - Country:US
Mailing Address - Phone:586-241-7088
Mailing Address - Fax:585-585-9555
Practice Address - Street 1:15730 MOK AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2367
Practice Address - Country:US
Practice Address - Phone:586-241-7088
Practice Address - Fax:585-585-9555
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2023-05-11
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Provider Licenses
StateLicense IDTaxonomies
MI4704260135163WM0705X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health