Basic Information
| Provider Information | |||||||||
| NPI: | 1396723664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RN, CHE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD. | ||||||||
| Address2: | #7440 COMMANDER, USA MEDDAC-AK, ATTN: MCUC-MMD-QM | ||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997037440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073535418 | ||||||||
| FaxNumber: | 9073534845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY RD | ||||||||
| Address2: | #7440 COMMANDER, USA MEDDAC-AK, ATTN: MCUC-MMD-QM | ||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073535418 | ||||||||
| FaxNumber: | 9073534845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 18147 | AK | Y | Nursing Service Providers | Registered Nurse |
No ID Information.