Healthcare Provider Details

I. General information

NPI: 1841289022
Provider Name (Legal Business Name): STEPHANIE R WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 RESEARCH PARKWAY
COLORADO SPRINGS CO
80918
US

IV. Provider business mailing address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1604
US

V. Phone/Fax

Practice location:
  • Phone: 719-522-1134
  • Fax: 719-598-7229
Mailing address:
  • Phone: 719-866-6568
  • Fax: 719-538-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0034435
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: