=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922244805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE D WALLACE AU.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2008
-----------------------------------------------------
Last Update Date | 03/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 2ND ST S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-385-3620
-----------------------------------------------------
Fax | 208-386-3621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1100
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83701-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-489-4690
-----------------------------------------------------
Fax | 208-489-4072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AUD-1246
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 21617
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AUD1246
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------