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: 07/08/2026
Certification Date: 07/08/2026
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

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 919-259-4678
  • Fax:
Mailing address:
  • Phone: 206-520-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD.MD.60250818
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: