Healthcare Provider Details

I. General information

NPI: 1770217267
Provider Name (Legal Business Name): ASHLEY WALLACE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CROSSING BLVD
FRAMINGHAM MA
01702-5555
US

IV. Provider business mailing address

100 CROSSING BLVD
FRAMINGHAM MA
01702-5555
US

V. Phone/Fax

Practice location:
  • Phone: 888-964-6681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5551
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: