Provider Demographics
NPI:1841742863
Name:WALLACE, KRISTINE (ND)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10153 N. HAMPTON AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209
Mailing Address - Country:US
Mailing Address - Phone:480-535-5688
Mailing Address - Fax:
Practice Address - Street 1:10153 N. HAMPTON AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209
Practice Address - Country:US
Practice Address - Phone:480-535-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16-1559175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath