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General NPI Number Information
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NPI Number | 1033882956
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Entity Type | Individual
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Provider Name | MRS. KAITLIN JEAN WALLACE
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Gender | Female
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Dates
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Enumeration Date | 07/27/2021
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Last Update Date | 07/27/2021
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Provider Practice Location Address
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Address Line | 918 W BRUNDAGE LN
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City | SHERIDAN
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State | WY
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Zip | 82801-5827
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Country | US
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Telephone | 307-673-4420
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Fax |
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Provider Business Mailing Address
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Address Line | 814 N CUSTER ST APT 102
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City | SHERIDAN
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State | WY
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Zip | 82801-3749
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Country | US
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Telephone | 818-209-8709
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-1570
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License Number State | WY
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