Provider Demographics
NPI:1275258717
Name:WALLACE, ALYSSA ANN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:ANN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 700360
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-0360
Mailing Address - Country:US
Mailing Address - Phone:918-382-7300
Mailing Address - Fax:918-392-3471
Practice Address - Street 1:4103 S YALE AVE STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6002
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:918-392-3471
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator