MEDICARE: VERONICA 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	164W00000X	Licensed Practical Nurse	303777-031	WI

General Provider Information

NPI Number	:	1568290948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERONICA WALLACE

Provider Business Mailing Address
First Line	:	5475A N 40TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-4617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5475A N 40TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-4617
Country	:	US
Telephone Number	:	414-416-7625
Fax Number	:

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

Provider Enumeration Date	:	07/25/2024
Last Update Date	:	07/25/2024

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