1043312226 NPI number — MISS DAPHNE WALLACE PT

Table of content: MISS DAPHNE WALLACE PT (NPI 1043312226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043312226 NPI number — MISS DAPHNE WALLACE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
DAPHNE
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043312226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 OSLO CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35211-5965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-944-3944
Provider Business Mailing Address Fax Number:
205-413-4914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 OSLO CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35211-5965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-944-3944
Provider Business Practice Location Address Fax Number:
205-413-4914
Provider Enumeration Date:
09/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  PTH4642 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51532180 . This is a "BCBS PROVIDER # FOR ARC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 890015770 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 515-30526 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".