Provider Demographics
NPI:1871087106
Name:WALLACE, HEIDI MARIE
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:MARIE
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:423-317-9344
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:501 ADESA BLVD STE A150
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-6719
Practice Address - Country:US
Practice Address - Phone:865-986-8082
Practice Address - Fax:865-986-5890
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide