MEDICARE: JOAN WALLACE MA

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	225700000X	Massage Therapist	MA53653	FL

General Provider Information

NPI Number	:	1629230776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOAN WALLACE MA

Provider Business Mailing Address
First Line	:	4383 NORTHLAKE BLVD
Second Line	:	SUITE 309
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6253
Country	:	US
Telephone Number	:	561-775-4900
Fax Number	:	561-775-0003

Provider Business Practice Location Address
First Line	:	4383 NORTHLAKE BLVD
Second Line	:	SUITE 309
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6253
Country	:	US
Telephone Number	:	561-775-4900
Fax Number	:	561-775-0003

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

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	06/30/2008

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Directions to “ JOAN WALLACE MA” Practice Location

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