Provider Demographics
NPI:1093387904
Name:WALLACE, MELANIE E
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:E
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 1:9028 RANDOLPH CIR
Mailing Address - Street 2:
Mailing Address - City:BEALETON
Mailing Address - State:VA
Mailing Address - Zip Code:22712-5647
Mailing Address - Country:US
Mailing Address - Phone:703-678-1123
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27268-0002
Practice Address - Country:US
Practice Address - Phone:336-841-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program