MEDICARE: LACEY WALLACE

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1255906814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY WALLACE

Provider Business Mailing Address
First Line	:	160 ARENDS RIDGE RD
Second Line	:
City	:	MARIETTA
State	:	OH
Zip	:	45750-5324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 ARENDS RIDGE RD
Second Line	:
City	:	MARIETTA
State	:	OH
Zip	:	45750-5324
Country	:	US
Telephone Number	:	740-706-4818
Fax Number	:

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

Provider Enumeration Date	:	05/25/2021
Last Update Date	:	05/25/2021

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Directions to “ LACEY WALLACE ” Practice Location

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