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General NPI Number Information
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NPI Number | 1194482620
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Entity Type | Individual
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Provider Name | KAITLIN BROOKE WALLACE PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 11/18/2021
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Last Update Date | 11/18/2021
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Provider Practice Location Address
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Address Line | 629 SMITHVIEW DR
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City | MARYVILLE
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State | TN
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Zip | 37803-6100
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Country | US
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Telephone | 865-984-8484
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Fax |
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Provider Business Mailing Address
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Address Line | 12516 LOVELACE RD
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City | KNOXVILLE
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State | TN
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Zip | 37932-1703
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Country | US
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Telephone | 865-804-5796
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11686
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License Number State | TN
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