MEDICARE: KRISTEN NICOLE 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	103K00000X	Behavior Analyst	1-21-51057	NC

General Provider Information

NPI Number	:	1619548336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN NICOLE WALLACE

Provider Business Mailing Address
First Line	:	2810 COLISEUM CENTRE DR STE 520
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-3252
Country	:	US
Telephone Number	:	980-785-1113
Fax Number	:	980-785-1114

Provider Business Practice Location Address
First Line	:	834 TYVOLA RD STE 126
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-3598
Country	:	US
Telephone Number	:	980-785-1113
Fax Number	:	980-785-1114

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

Provider Enumeration Date	:	07/03/2021
Last Update Date	:	07/24/2024

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Directions to “ KRISTEN NICOLE WALLACE ” Practice Location

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