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General NPI Number Information
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NPI Number | 1235305889
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Entity Type | Individual
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Provider Name | CYNTHIA KAY WALLACE MD
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Gender | Female
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Dates
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Enumeration Date | 05/05/2008
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Last Update Date | 06/24/2024
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Provider Practice Location Address
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Address Line | 1959 NE PACIFIC STREET BOX 356423
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City | SEATTLE
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State | WA
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Zip | 98195-2223
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Country | US
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Telephone | 919-259-4678
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Fax |
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Provider Business Mailing Address
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Address Line | 19425 TOLLHOUSE RD
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City | CLOVIS
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State | CA
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Zip | 93619-9758
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Country | US
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Telephone |
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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 | 207RH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
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License Number | MD60250818
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207RH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
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License Number | C139714
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | MD60250818
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License Number State | WA
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Taxonomy #4
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | MD60250818
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License Number State | WA
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Taxonomy #5
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | C139714
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD60250818
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License Number State | WA
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