Provider Demographics
NPI:1518510122
Name:WALLACE, PENNY SUE
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:SUE
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 1:6825 N STATE ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-6730
Mailing Address - Country:US
Mailing Address - Phone:419-782-4196
Mailing Address - Fax:
Practice Address - Street 1:6825 N STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-6730
Practice Address - Country:US
Practice Address - Phone:419-782-4196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker