Provider Demographics
NPI:1790249100
Name:WALLACE, KAITLYNN
Entity Type:Individual
Prefix:
First Name:KAITLYNN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 E FOREST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ACAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:95220-9573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S AVE K
Practice Address - Street 2:STATION 3, SHROC
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-562-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
390200000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program