Healthcare Provider Details

I. General information

NPI: 1497568455
Provider Name (Legal Business Name): MS. TYRESHA LYNA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45528 COOSAN CT
GREAT MILLS MD
20634-2454
US

IV. Provider business mailing address

1517 REISTERSTOWN RD
PIKESVILLE MD
21208-4325
US

V. Phone/Fax

Practice location:
  • Phone: 443-404-9473
  • Fax:
Mailing address:
  • Phone: 410-541-1316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: