Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT. 007669 | OH |
NPI | 1003153826 |
---|---|
Provider Name | Kimberly K Wallace |
First Address | North Canton, OH 44720-2593 |
Second Address | North Canton, OH 44720-2593 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2013 |
Last Update Date | 14/01/2013 |