Provider Demographics
NPI:1659594729
Name:WALLACE, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
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 1:228 DRAWYERS DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-6824
Mailing Address - Country:US
Mailing Address - Phone:302-376-8286
Mailing Address - Fax:
Practice Address - Street 1:61 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-2439
Practice Address - Country:US
Practice Address - Phone:302-324-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist