Healthcare Provider Details

I. General information

NPI: 1730405598
Provider Name (Legal Business Name): ERIN MICHELLE WALLACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 MOUNT HOOD AVE STE 160
WOODBURN OR
97071-9263
US

IV. Provider business mailing address

PO BOX 3417
PORTLAND OR
97208-3417
US

V. Phone/Fax

Practice location:
  • Phone: 971-983-5214
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD164348
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: