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NPI Code Detail

MEDICARE: CYNTHIA ELAINE FAY WALLACE

MEDICARE: CYNTHIA ELAINE FAY 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
1175T00000XPeer SpecialistMI

General Provider Information

NPI Number : 1437019924
Entity Type Code : Individual
Provider Name (Legal Business Name) : CYNTHIA ELAINE FAY WALLACE
Provider Business Mailing Address
First Line : 1115 BALL AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49505-5904
Country : US
Telephone Number : 616-456-6571
Fax Number :
Provider Business Practice Location Address
First Line : 1115 BALL AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49505-5904
Country : US
Telephone Number : 616-456-6571
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/17/2025
Last Update Date : 12/09/2025

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Directions to “ CYNTHIA ELAINE FAY WALLACE ” Practice Location

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