Healthcare Provider Details

I. General information

NPI: 1902716814
Provider Name (Legal Business Name): KYLIE WALLACE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

IV. Provider business mailing address

1258 SCHEURING RD APT 13
DE PERE WI
54115-1061
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9268
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: