=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649520511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. JAMIE WALLACE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 469 W PUTNAM AVE
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-6895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-869-5546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 469 W PUTNAM AVE
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-6895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-869-5546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 009438
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------