=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265324511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE WALLACE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3739 N 38TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-672-3139
-----------------------------------------------------
Fax | 262-672-3139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3739 N 38TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-672-3139
-----------------------------------------------------
Fax | 262-672-3139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | W4201789495600
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------