MEDICARE: LILIANNA 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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1548012198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILIANNA WALLACE

Provider Business Mailing Address
First Line	:	10527 JADE WALK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89179-1489
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10527 JADE WALK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89179-1489
Country	:	US
Telephone Number	:	312-639-3130
Fax Number	:

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

Provider Enumeration Date	:	04/04/2024
Last Update Date	:	04/04/2024

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Directions to “ LILIANNA WALLACE ” Practice Location

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