MEDICARE: LEAH WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251X00000X	Supports Brokerage Agency		OH

General Provider Information

NPI Number	:	1962254557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH WALLACE

Provider Business Mailing Address
First Line	:	1734 WICKFORD RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1208
Country	:	US
Telephone Number	:	216-374-1546
Fax Number	:

Provider Business Practice Location Address
First Line	:	1734 WICKFORD RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1208
Country	:	US
Telephone Number	:	216-374-1546
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2024
Last Update Date	:	04/06/2024

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Directions to “ LEAH WALLACE ” Practice Location

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