Provider Demographics
NPI:1245944354
Name:WALLACE, SAMRA (STNA)
Entity type:Individual
Prefix:
First Name:SAMRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 COMPASS WEST DR
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3439
Mailing Address - Country:US
Mailing Address - Phone:330-209-8925
Mailing Address - Fax:
Practice Address - Street 1:853 COMPASS WEST DR
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3439
Practice Address - Country:US
Practice Address - Phone:330-209-8925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400814711008376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide