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:F
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 1:8401 MAYLAND DR # 5766
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4648
Mailing Address - Country:US
Mailing Address - Phone:804-635-6535
Mailing Address - Fax:
Practice Address - Street 1:8401 MAYLAND DR # 5766
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4648
Practice Address - Country:US
Practice Address - Phone:804-635-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2025-06-26
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