MEDICARE: MRS. ALISSA NICOLE WALLACE P.T.

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	225100000X	Physical Therapist	05006292A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144244179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALISSA NICOLE WALLACE P.T.

Provider Business Mailing Address
First Line	:	25590 CORNELL RD
Second Line	:
City	:	ARCADIA
State	:	IN
Zip	:	46030-9612
Country	:	US
Telephone Number	:	317-697-5759
Fax Number	:

Provider Business Practice Location Address
First Line	:	25590 CORNELL RD
Second Line	:
City	:	ARCADIA
State	:	IN
Zip	:	46030-9612
Country	:	US
Telephone Number	:	317-697-5759
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	05/22/2008

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