Provider Demographics
NPI:1396161030
Name:WALLACE, NIKKI (LPN)
Entity type:Individual
Prefix:MS
First Name:NIKKI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3982 S FORDHAM PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2329
Mailing Address - Country:US
Mailing Address - Phone:513-264-2637
Mailing Address - Fax:
Practice Address - Street 1:3982 S FORDHAM PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2329
Practice Address - Country:US
Practice Address - Phone:513-264-2637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150310164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse