Provider Demographics
NPI:1467116400
Name:WALLIS, WACHIRA
Entity Type:Individual
Prefix:
First Name:WACHIRA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 GANDY BLVD N APT 6412
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-1543
Mailing Address - Country:US
Mailing Address - Phone:412-799-3377
Mailing Address - Fax:
Practice Address - Street 1:10601 GANDY BLVD N APT 6412
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-1543
Practice Address - Country:US
Practice Address - Phone:412-799-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA98518225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist