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General NPI Number Information
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NPI Number | 1144483033
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Entity Type | Individual
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Provider Name | TRACEY LYNN WALLACE AU.D., CCC/A
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Gender | Female
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Dates
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Enumeration Date | 07/09/2008
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Last Update Date | 10/16/2013
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Provider Practice Location Address
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Address Line | 14101 MOLLY BERRY RD
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City | BRANDYWINE
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State | MD
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Zip | 20613-2306
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Country | US
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Telephone | 301-793-3277
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Fax |
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Provider Business Mailing Address
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Address Line | 6368 COVENTRY WAY SUITE #146
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City | CLINTON
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State | MD
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Zip | 20735-2256
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Country | US
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Telephone | 301-793-3277
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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 | 237600000X
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Taxonomy Name | Audiologist-Hearing Aid Fitter
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License Number | 00718
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License Number State | MD
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