Provider Demographics
NPI:1568655348
Name:WALLACE, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
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 1:111 NATURE WALK PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5073
Mailing Address - Country:US
Mailing Address - Phone:904-230-7761
Mailing Address - Fax:904-230-7763
Practice Address - Street 1:111 NATURE WALK PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5073
Practice Address - Country:US
Practice Address - Phone:904-230-7761
Practice Address - Fax:904-230-7763
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist