Provider Demographics
NPI:1972068278
Name:WALLACE, MELISSA S (LPN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:S
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 1:2420 POLK ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-1837
Mailing Address - Country:US
Mailing Address - Phone:541-650-2236
Mailing Address - Fax:
Practice Address - Street 1:151 W 7TH AVE STE 163
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2676
Practice Address - Country:US
Practice Address - Phone:541-682-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201393584LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse