Healthcare Provider Details

I. General information

NPI: 1043468473
Provider Name (Legal Business Name): SHARON DENICE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 COVINGTON PIKE
MEMPHIS TN
38135-2281
US

IV. Provider business mailing address

3909 COVINGTON PIKE
MEMPHIS TN
38135-2281
US

V. Phone/Fax

Practice location:
  • Phone: 901-377-1011
  • Fax: 901-226-0463
Mailing address:
  • Phone: 901-377-1011
  • Fax: 901-226-0463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0000000663
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: