Provider Demographics
NPI:1124192703
Name:WALLACE, DONNA F (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:F
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
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Mailing Address - Street 1:3445 POST ROAD
Mailing Address - Street 2:J ARTHUR TRUDEAU MEMORIAL CENTER ATTN KIM RUELLE HR
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-7147
Mailing Address - Country:US
Mailing Address - Phone:401-739-2700
Mailing Address - Fax:401-737-8907
Practice Address - Street 1:3445 POST ROAD
Practice Address - Street 2:J ARTHUR TRUDEAU MEMORIAL CENTER ATTN KIM RUELLE HR
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-7147
Practice Address - Country:US
Practice Address - Phone:401-739-2700
Practice Address - Fax:401-737-8907
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RIRI 544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKC02260Medicaid