MEDICARE: THERESA 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
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1063947018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA WALLACE

Provider Business Mailing Address
First Line	:	2201 1/2 ROSLYN AVE
Second Line	:	APT 203
City	:	BALTIMORE
State	:	MD
Zip	:	21216-2522
Country	:	US
Telephone Number	:	443-468-2142
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 1/2 ROSLYN AVE
Second Line	:	APT 203
City	:	BALTIMORE
State	:	MD
Zip	:	21216-2522
Country	:	US
Telephone Number	:	443-468-2142
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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