Healthcare Provider Details

I. General information

NPI: 1154197929
Provider Name (Legal Business Name): HEATHER MARIE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 E CYPRESS AVE STE E
REDDING CA
96002-0283
US

IV. Provider business mailing address

3420 LITTLE ST
REDDING CA
96003-2231
US

V. Phone/Fax

Practice location:
  • Phone: 530-691-9940
  • Fax:
Mailing address:
  • Phone: 530-691-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: