Provider Demographics
NPI:1518299197
Name:WALLACE, STEPHANIE LOUISE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LOUISE
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 1:1122 KENILWORTH DR STE 317
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2146
Mailing Address - Country:US
Mailing Address - Phone:410-296-4616
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST STE 4226
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-296-4616
Practice Address - Fax:410-337-5068
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR160036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD570079500Medicaid