Healthcare Provider Details

I. General information

NPI: 1518620806
Provider Name (Legal Business Name): ANIETIE UKPE-WALLACE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIA UKPE-WALLACE PT, DPT

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WEBSTER STREET
ALAMEDA CA
94501-9450
US

IV. Provider business mailing address

3001 JORDAN RD
OAKLAND CA
94602-3530
US

V. Phone/Fax

Practice location:
  • Phone: 510-545-3541
  • Fax:
Mailing address:
  • Phone: 914-400-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT297733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: