Healthcare Provider Details

I. General information

NPI: 1659594729
Provider Name (Legal Business Name): KRISTEN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 CORPORATE CIR
NEW CASTLE DE
19720-2439
US

IV. Provider business mailing address

228 DRAWYERS DR
MIDDLETOWN DE
19709-6824
US

V. Phone/Fax

Practice location:
  • Phone: 302-324-4444
  • Fax:
Mailing address:
  • Phone: 302-376-8286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: