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General NPI Number Information
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NPI Number | 1457019135
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Entity Type | Individual
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Provider Name | BRANDI WALLACE HAIR LOSS SPECIALIST
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Gender | Female
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Dates
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Enumeration Date | 11/30/2021
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Last Update Date | 12/31/2021
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Provider Practice Location Address
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Address Line | 235 W MAIN ST STE E
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City | SALISBURY
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State | MD
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Zip | 21801-4868
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Country | US
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Telephone | 443-447-2028
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Fax |
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Provider Business Mailing Address
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Address Line | 808 S SCHUMAKER DR APT 1D
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City | SALISBURY
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State | MD
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Zip | 21804-9289
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Country | US
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Telephone | 443-447-2028
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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 | 1744P3200X
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Taxonomy Name | Prosthetics Case Management
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License Number | 418829
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License Number State | MD
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