Provider Demographics
NPI:1962194506
Name:WALLACE, LATIA MARIE (LPN)
Entity type:Individual
Prefix:MISS
First Name:LATIA
Middle Name:MARIE
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 1:134 ASHLAND LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-8877
Mailing Address - Country:US
Mailing Address - Phone:440-665-1662
Mailing Address - Fax:
Practice Address - Street 1:134 ASHLAND LN
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-8877
Practice Address - Country:US
Practice Address - Phone:440-665-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH180564164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse