Provider Demographics
NPI:1205177631
Name:WALLACE, RODNEY T
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 DOUGLAS ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2114
Mailing Address - Country:US
Mailing Address - Phone:202-557-8857
Mailing Address - Fax:
Practice Address - Street 1:2036 DOUGLAS ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2114
Practice Address - Country:US
Practice Address - Phone:202-557-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide