Provider Demographics
NPI:1730828666
Name:WALLACE, GENEVA KAY
Entity type:Individual
Prefix:
First Name:GENEVA
Middle Name:KAY
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 1:3730 LOG CABIN LN
Mailing Address - Street 2:
Mailing Address - City:DINGESS
Mailing Address - State:WV
Mailing Address - Zip Code:25671-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3730 LOG CABIN LN
Practice Address - Street 2:
Practice Address - City:DINGESS
Practice Address - State:WV
Practice Address - Zip Code:25671-1402
Practice Address - Country:US
Practice Address - Phone:304-752-1769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant