Provider Demographics
NPI:1760676019
Name:WALLACE, AUBREY KATHLEEN (ND)
Entity Type:Individual
Prefix:DR
First Name:AUBREY
Middle Name:KATHLEEN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21827 76TH AVE W STE 202
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7981
Mailing Address - Country:US
Mailing Address - Phone:425-835-0359
Mailing Address - Fax:425-835-0821
Practice Address - Street 1:21827 76TH AVE W STE 202
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7981
Practice Address - Country:US
Practice Address - Phone:425-835-0359
Practice Address - Fax:425-835-0821
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT 60477240175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046966Medicaid