Healthcare Provider Details

I. General information

NPI: 1255542858
Provider Name (Legal Business Name): DANA WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13255 ROAD 22K
CLOVERDALE OH
45827-9454
US

IV. Provider business mailing address

13255 ROAD 22K
CLOVERDALE OH
45827-9454
US

V. Phone/Fax

Practice location:
  • Phone: 419-532-3747
  • Fax:
Mailing address:
  • Phone: 419-532-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN278652
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: