Provider Demographics
NPI:1699575837
Name:WALLACE, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
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 1:202 S EARL ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45896-8418
Mailing Address - Country:US
Mailing Address - Phone:937-565-0101
Mailing Address - Fax:
Practice Address - Street 1:202 S EARL ST
Practice Address - Street 2:
Practice Address - City:WAYNESFIELD
Practice Address - State:OH
Practice Address - Zip Code:45896-8418
Practice Address - Country:US
Practice Address - Phone:937-565-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide