Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | PTH4642 | AL |
NPI | 1043312226 |
---|---|
Provider Name | Miss Daphne Wallace |
First Address | Birmingham, AL 35211-5965 |
Second Address | Birmingham, AL 35211-5965 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2006 |
Last Update Date | 06/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
515-30526 | BCBS (01) | AL |
51532180 | BCBS PROVIDER # FOR ARC (01) | AL |
890015770 | (05) | AL |