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General NPI Number Information
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NPI Number | 1740252576
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Entity Type | Individual
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Provider Name | CELESTE NICOLE WALLACE D.O.
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Gender | Female
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Dates
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Enumeration Date | 02/06/2006
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 802 GREEN VALLEY RD SUITE 210
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City | GREENSBORO
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State | NC
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Zip | 27408-7041
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Country | US
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Telephone | 336-802-2536
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Fax | 336-802-2534
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Provider Business Mailing Address
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Address Line | 1701 WESTCHESTER DR SUITE 850
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City | HIGH POINT
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State | NC
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Zip | 27262-7008
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Country | US
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Telephone | 336-802-2536
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Fax | 336-802-2534
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 34--008564
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License Number State | OH
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