Provider Demographics
NPI:1508145715
Name:WALLACE, KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
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 1:760 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1235
Mailing Address - Country:US
Mailing Address - Phone:415-836-1772
Mailing Address - Fax:
Practice Address - Street 1:1235 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2705
Practice Address - Country:US
Practice Address - Phone:415-255-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker