Basic Information
| Provider Information | |||||||||
| NPI: | 1053907642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | WALONDA | ||||||||
| MiddleName: | SHELISE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185124997 | ||||||||
| FaxNumber: | 3186006095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185124997 | ||||||||
| FaxNumber: | 3186006095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2020 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.