MEDICARE: TAHIRA 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	261QS1000X	Student Health Clinic/Center		MD

General Provider Information

NPI Number	:	1205783941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAHIRA WALLACE

Provider Business Mailing Address
First Line	:	14929 NOTLEY RD
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20905-5821
Country	:	US
Telephone Number	:	240-444-9603
Fax Number	:

Provider Business Practice Location Address
First Line	:	14929 NOTLEY RD
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20905-5821
Country	:	US
Telephone Number	:	240-444-9603
Fax Number	:

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

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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Directions to “ TAHIRA WALLACE ” Practice Location

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