MEDICARE: LEONTINE WALLACE RN, BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0200X	Pediatric Registered Nurse	4704318023	MI
2	163WL0100X	Lactation Consultant (Registered Nurse)	4704318023	MI

General Provider Information

NPI Number	:	1053800649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONTINE WALLACE RN, BSN

Provider Business Mailing Address
First Line	:	2300 HAGGERTY RD STE 2110
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2191
Country	:	US
Telephone Number	:	248-926-1420
Fax Number	:	248-926-5338

Provider Business Practice Location Address
First Line	:	2300 HAGGERTY RD STE 2110
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2191
Country	:	US
Telephone Number	:	248-926-1420
Fax Number	:	248-926-5338

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	05/09/2018

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