Provider Demographics
NPI:1790124378
Name:WALLACE, TARA (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 BABBLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8338
Mailing Address - Country:US
Mailing Address - Phone:636-577-1216
Mailing Address - Fax:636-294-0837
Practice Address - Street 1:2633 BABBLE CREEK LN
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8338
Practice Address - Country:US
Practice Address - Phone:636-577-1216
Practice Address - Fax:636-294-0837
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001032642174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist