Provider Demographics
NPI:1558089763
Name:WALLACE, KATIE ANN (ATC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S VINE ST APT 201
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-2766
Mailing Address - Country:US
Mailing Address - Phone:406-672-2503
Mailing Address - Fax:
Practice Address - Street 1:5670 GREENWOOD PLAZA BLVD STE LL110
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2448
Practice Address - Country:US
Practice Address - Phone:303-694-9193
Practice Address - Fax:303-779-0566
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer