Provider Demographics
NPI:1154655231
Name:WALLACE, JOHN ANTHONY (BA, MA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANTHONY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MARLIN LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-5982
Mailing Address - Country:US
Mailing Address - Phone:865-898-7448
Mailing Address - Fax:
Practice Address - Street 1:2702 FARRELL RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-6505
Practice Address - Country:US
Practice Address - Phone:919-776-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist