Healthcare Provider Details

I. General information

NPI: 1396921722
Provider Name (Legal Business Name): TRISTIN HC WALLACE ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14201 NE 20TH AVE SUITE 1102
VANCOUVER WA
98686-6410
US

IV. Provider business mailing address

14201 NE 20TH AVE SUITE 1102
VANCOUVER WA
98686-6410
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-7373
  • Fax: 360-882-7673
Mailing address:
  • Phone: 360-882-7373
  • Fax: 360-882-7673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT 60083023
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: