Healthcare Provider Details

I. General information

NPI: 1235305889
Provider Name (Legal Business Name): CYNTHIA KAY WALLACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC STREET BOX 356423
SEATTLE WA
98195-2223
US

IV. Provider business mailing address

19425 TOLLHOUSE RD
CLOVIS CA
93619-9758
US

V. Phone/Fax

Practice location:
  • Phone: 919-259-4678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberMD60250818
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberC139714
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD60250818
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60250818
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC139714
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60250818
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: