Provider Demographics
NPI:1609665736
Name:WALLACE, COURTNEY A (STNA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 JOHNS ST APT A
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-1273
Mailing Address - Country:US
Mailing Address - Phone:440-935-7827
Mailing Address - Fax:
Practice Address - Street 1:125 JOHNS ST APT A
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090-1273
Practice Address - Country:US
Practice Address - Phone:440-935-7827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602590990223374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty