Healthcare Provider Details

I. General information

NPI: 1639783848
Provider Name (Legal Business Name): CHRISTINA N WALLACE MASSAGE PRACTIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA WALLACE BERRY

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 OAK STREET
PENNGROVE CA
94951
US

IV. Provider business mailing address

PO BOX 853
PENNGROVE CA
94951-0853
US

V. Phone/Fax

Practice location:
  • Phone: 707-431-1223
  • Fax:
Mailing address:
  • Phone: 707-431-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number30660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: