Provider Demographics
NPI:1376021865
Name:THOMPSON-WALLACE, ELAINE MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MARIE
Last Name:THOMPSON-WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3022
Mailing Address - Country:US
Mailing Address - Phone:609-273-7101
Mailing Address - Fax:
Practice Address - Street 1:1725 BELL AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3022
Practice Address - Country:US
Practice Address - Phone:609-273-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP05974700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse