Individual
HATTIE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
14625 S MOUNTAIN PKWY, APT 1056, PHOENIX, AZ 85044-7142
(602) 565-2159
Mailing address
14625 S MOUNTAIN PKWY, APT 1056, PHOENIX, AZ 85044-7142
(602) 565-2159
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LP044351
AZ
Other
Enumeration date
03/02/2012
Last updated
03/02/2012
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