=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972165264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN ARLEEN WALLACE-ROSSIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 11/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3681 LEAPHART RD STE A
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-590-8548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3681 LEAPHART RD STE A
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-590-8548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 094809
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------