Provider Demographics
NPI:1760373880
Name:WALLACE-MOORE, BETTIE L
Entity type:Individual
Prefix:
First Name:BETTIE
Middle Name:L
Last Name:WALLACE-MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETTIE
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6178 CROSS BEND CT
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2854
Mailing Address - Country:US
Mailing Address - Phone:269-753-9727
Mailing Address - Fax:
Practice Address - Street 1:6178 CROSS BEND CT
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2854
Practice Address - Country:US
Practice Address - Phone:269-753-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula