Provider Demographics
NPI:1710562756
Name:WALLACE, MELANIE LYNNE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LYNNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:LYNNE
Other - Last Name:NANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5949 SENTINEL RD APT 5
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-3525
Mailing Address - Country:US
Mailing Address - Phone:404-992-3366
Mailing Address - Fax:
Practice Address - Street 1:70 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1537
Practice Address - Country:US
Practice Address - Phone:404-992-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker