Provider Demographics
NPI:1760830822
Name:WALLIS, MARY (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 RUE SAINT FRANCOIS
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4923
Mailing Address - Country:US
Mailing Address - Phone:314-921-3366
Mailing Address - Fax:
Practice Address - Street 1:895 RUE SAINT FRANCOIS
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-4923
Practice Address - Country:US
Practice Address - Phone:314-921-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007002923171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist