Provider Demographics
NPI:1144060807
Name:WALLACE, DELANIA MICHELLE
Entity type:Individual
Prefix:
First Name:DELANIA
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14180 HIGHWAY 44 LOT 1
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-6962
Mailing Address - Country:US
Mailing Address - Phone:337-422-8983
Mailing Address - Fax:
Practice Address - Street 1:14635 S HARRELLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2959
Practice Address - Country:US
Practice Address - Phone:225-349-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator