Healthcare Provider Details

I. General information

NPI: 1689802662
Provider Name (Legal Business Name): TIFFANY DAWN WALLACE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

IV. Provider business mailing address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

V. Phone/Fax

Practice location:
  • Phone: 407-206-4500
  • Fax: 407-643-2802
Mailing address:
  • Phone: 407-206-4500
  • Fax: 407-643-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24764
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT24764
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: