Provider Demographics
NPI:1619353224
Name:WALLACE, LETITIA J (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LETITIA
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 BANNEKER DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5635
Mailing Address - Country:US
Mailing Address - Phone:804-972-6569
Mailing Address - Fax:
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-862-8002
Practice Address - Fax:804-862-8023
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001236086163W00000X
VA0024193187363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse