| Doctor Name: | KIMBERLY WALLACE |
| NPI Number: | 1750785622 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LPN |
| License Number: | 290441 |
| Business Practice Address: | 138 North Court Street Wampsville, NY - 13163 |
| Business Phone Number: | 3153662490 |
| Business Fax Number: | |
| Mailing Address: | 2401 Clark Rd, CANASTOTA |
| State: | NY |
| Postal Code: | 130324759 |
| Phone Number: | 3153968515 |
| Fax Number: | |
| NPI Enumeration Date: | 10/21/2014 |
| NPI Last Update Date: | 10/21/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 164W00000X |
| License Number: | 290441 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Licensed Practical Nurse |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual with post-high school vocational training and practical experience in the provision of nursing care at a level less than that required for certification as a Registered Nurse. Requirements for education, experience, licensure, and job responsibilities vary among the states. |