Healthcare Provider Details

I. General information

NPI: 1669479713
Provider Name (Legal Business Name): MELISSA A. WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 WAYCROSS RD
CINCINNATI OH
45240-3184
US

IV. Provider business mailing address

752 WAYCROSS RD
CINCINNATI OH
45240-3184
US

V. Phone/Fax

Practice location:
  • Phone: 513-825-9595
  • Fax: 513-589-3747
Mailing address:
  • Phone: 513-825-9595
  • Fax: 513-589-3747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34007996W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: