Individual
CHANTAY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
142 W 143RD ST APT 3A, NEW YORK, NY 10030-1665
(917) 916-2216
Mailing address
142 W 143RD ST APT 3A, NEW YORK, NY 10030-1665
(917) 916-2216
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
766721987
NY
Other
Enumeration date
11/28/2018
Last updated
11/28/2018
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