Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT005811L | PA |
NPI | 1003075524 |
---|---|
Provider Name | Ms. Wendy Wallace |
First Address | Lemoyne, PA 17043-1242 |
Second Address | Lemoyne, PA 17043-1242 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2008 |
Last Update Date | 10/06/2008 |