Provider Demographics
NPI:1740158377
Name:WALLACE, JYNUINE
Entity type:Individual
Prefix:
First Name:JYNUINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ARLENE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH VERSAILLES
Mailing Address - State:PA
Mailing Address - Zip Code:15137-2432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 ARLENE AVE
Practice Address - Street 2:
Practice Address - City:NORTH VERSAILLES
Practice Address - State:PA
Practice Address - Zip Code:15137-2432
Practice Address - Country:US
Practice Address - Phone:412-304-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist