Provider Demographics
NPI:1558091983
Name:WALLACE, STEPHANIE (NEMT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:ESOPUS
Mailing Address - State:NY
Mailing Address - Zip Code:12429-0061
Mailing Address - Country:US
Mailing Address - Phone:845-901-9966
Mailing Address - Fax:
Practice Address - Street 1:60 MAIN ST # 61
Practice Address - Street 2:
Practice Address - City:ESOPUS
Practice Address - State:NY
Practice Address - Zip Code:12429-9800
Practice Address - Country:US
Practice Address - Phone:845-901-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company