Provider Demographics
NPI:1619260478
Name:WALLACE, KERRI ANNE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:ANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:KERRI
Other - Middle Name:ANNE
Other - Last Name:FLAUGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 W 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2306
Practice Address - Country:US
Practice Address - Phone:636-239-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008036904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist