Provider Demographics
NPI:1467046235
Name:WALLACE, AKEISHA D
Entity type:Individual
Prefix:
First Name:AKEISHA
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 SELWYN RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2343
Mailing Address - Country:US
Mailing Address - Phone:440-691-8126
Mailing Address - Fax:
Practice Address - Street 1:887 SELWYN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44112-2343
Practice Address - Country:US
Practice Address - Phone:440-691-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant