Healthcare Provider Details

I. General information

NPI: 1366745804
Provider Name (Legal Business Name): KRISTIN NICOLE WALLACE M.S., OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

2935 N RANKIN ST
APPLETON WI
54911-1518
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2000
  • Fax:
Mailing address:
  • Phone: 920-659-2887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: