Provider Demographics
NPI:1285199083
Name:WALLACE, KELSEY ANN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
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 1:339 BUHL BLVD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-3711
Mailing Address - Country:US
Mailing Address - Phone:724-866-6203
Mailing Address - Fax:
Practice Address - Street 1:339 BUHL BLVD
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:PA
Practice Address - Zip Code:16146-3711
Practice Address - Country:US
Practice Address - Phone:724-866-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program