Healthcare Provider Details

I. General information

NPI: 1508720251
Provider Name (Legal Business Name): BRIANA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 LINGLESTOWN RD STE 108
HARRISBURG PA
17112-8534
US

IV. Provider business mailing address

4400 LINGLESTOWN RD STE 108
HARRISBURG PA
17112-8534
US

V. Phone/Fax

Practice location:
  • Phone: 717-998-1442
  • Fax:
Mailing address:
  • Phone: 717-998-1442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: