Provider Demographics
NPI:1346535358
Name:WALLACE, CHRISTI ANN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTI
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTI
Other - Middle Name:ANN
Other - Last Name:MUGFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:1302 MINNICH RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2052
Practice Address - Country:US
Practice Address - Phone:260-458-3200
Practice Address - Fax:260-458-3205
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072918A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine