Provider Demographics
NPI:1609365873
Name:WALLACE, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
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 1:8577 CORYDON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47136-9434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4915 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9426
Practice Address - Country:US
Practice Address - Phone:812-945-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist