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General NPI Number Information
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NPI Number | 1831578012
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Entity Type | Individual
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Provider Name | KATHRYN NICOLE WALLACE PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 05/21/2015
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Last Update Date | 05/22/2015
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Provider Practice Location Address
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Address Line | 320 ALISAL RD STE 406
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City | SOLVANG
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State | CA
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Zip | 93463-3750
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Country | US
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Telephone | 805-688-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 5560 EL POMAR DR
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City | TEMPLETON
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State | CA
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Zip | 93465-8555
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Country | US
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Telephone | 805-610-0657
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 42600
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License Number State | CA
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