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NPI Code Detail

MEDICARE: BIANCA NICHOLE WALLACE

MEDICARE: BIANCA NICHOLE WALLACE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1374J00000XDoula
2225700000XMassage Therapist9289AR

General Provider Information

NPI Number : 1063242337
Entity Type Code : Individual
Provider Name (Legal Business Name) : BIANCA NICHOLE WALLACE
Provider Business Mailing Address
First Line : 31 E CENTER ST STE 205
Second Line :
City : FAYETTEVILLE
State : AR
Zip : 72701-5385
Country : US
Telephone Number : 479-388-1513
Fax Number :
Provider Business Practice Location Address
First Line : 31 E CENTER ST STE 205
Second Line :
City : FAYETTEVILLE
State : AR
Zip : 72701-5385
Country : US
Telephone Number : 479-388-1513
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2024
Last Update Date : 08/02/2024

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Directions to “ BIANCA NICHOLE WALLACE ” Practice Location

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