MEDICARE: LAJUANA 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	225200000X	Physical Therapy Assistant	2057823	TX

General Provider Information

NPI Number	:	1902014079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAJUANA WALLACE

Provider Business Mailing Address
First Line	:	1304 TANGLEWOOD DR APT A
Second Line	:
City	:	WESTWEGO
State	:	LA
Zip	:	70094-5249
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8039 SCYENE CIR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-5534
Country	:	US
Telephone Number	:	972-437-9389
Fax Number	:

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

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	09/06/2007

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