Provider Demographics
NPI:1639783848
Name:WALLACE, CHRISTINA N (MASSAGE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MASSAGE PRACTIONER
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:WALLACE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:PENNGROVE
Mailing Address - State:CA
Mailing Address - Zip Code:94951-0853
Mailing Address - Country:US
Mailing Address - Phone:707-431-1223
Mailing Address - Fax:
Practice Address - Street 1:308 OAK STREET
Practice Address - Street 2:
Practice Address - City:PENNGROVE
Practice Address - State:CA
Practice Address - Zip Code:94951
Practice Address - Country:US
Practice Address - Phone:707-431-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30660225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist