Provider Demographics
NPI:1780024646
Name:WALLACE, NYRISS AUDREY
Entity Type:Individual
Prefix:MRS
First Name:NYRISS
Middle Name:AUDREY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NYRISS
Other - Middle Name:AUDREY
Other - Last Name:GNEME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:550 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2718
Mailing Address - Country:US
Mailing Address - Phone:763-236-5000
Mailing Address - Fax:
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104351225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist