Provider Demographics
NPI:1790562510
Name:WALLACE, CANDACE (CPT)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 SECURITY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5284
Mailing Address - Country:US
Mailing Address - Phone:443-272-1423
Mailing Address - Fax:443-658-0623
Practice Address - Street 1:6340 SECURITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-5284
Practice Address - Country:US
Practice Address - Phone:443-272-1423
Practice Address - Fax:443-658-0623
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy