Provider Demographics
NPI:1053063834
Name:WALLACE, IMA LATOYA
Entity Type:Individual
Prefix:
First Name:IMA
Middle Name:LATOYA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9951 ATLANTIC BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6574
Mailing Address - Country:US
Mailing Address - Phone:833-434-5223
Mailing Address - Fax:888-686-6271
Practice Address - Street 1:9951 ATLANTIC BLVD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6574
Practice Address - Country:US
Practice Address - Phone:833-434-5223
Practice Address - Fax:888-686-6271
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other