Healthcare Provider Details

I. General information

NPI: 1245391432
Provider Name (Legal Business Name): RACHEL WALLACE TELLEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHEL ELIZABETH WALLACE MD

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CESAR CHAVEZ ST
W. ST. PAUL MN
55107-2226
US

IV. Provider business mailing address

3714 FARMSTEAD PATH
WOODBURY MN
55129-6723
US

V. Phone/Fax

Practice location:
  • Phone: 651-222-1816
  • Fax: 651-222-1305
Mailing address:
  • Phone: 202-316-5633
  • Fax: 651-222-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56008
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: