MEDICARE: DR. COURTNEY NICOLE WALLACE AUD, CCC-A, F/AAA

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	231H00000X	Audiologist

General Provider Information

NPI Number	:	1508396789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COURTNEY NICOLE WALLACE AUD, CCC-A, F/AAA

Provider Business Mailing Address
First Line	:	202 7TH ST W APT 515
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-3094
Country	:	US
Telephone Number	:	630-303-3209
Fax Number	:

Provider Business Practice Location Address
First Line	:	2530 CHICAGO AVE STE 450
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4127
Country	:	US
Telephone Number	:	612-813-7610
Fax Number	:

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

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	07/21/2022

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