Provider Demographics
NPI:1144929423
Name:WALLACE, TANESIA
Entity type:Individual
Prefix:
First Name:TANESIA
Middle Name:
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 1:870 SOUTHMEADOW CIR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-6116
Mailing Address - Country:US
Mailing Address - Phone:513-236-7764
Mailing Address - Fax:
Practice Address - Street 1:5333 BLOSSOM ST APT 312
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45011-8775
Practice Address - Country:US
Practice Address - Phone:513-236-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH323801911210376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide