Provider Demographics
NPI:1396819884
Name:WALLACE, ANDREA LYNN (MS)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 WEST LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3377
Mailing Address - Country:US
Mailing Address - Phone:209-476-3427
Mailing Address - Fax:209-476-3142
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-3427
Practice Address - Fax:209-476-3142
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 2352231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist