Provider Demographics
NPI:1891010435
Name:WALLACE, LATAUNYA B (PT)
Entity Type:Individual
Prefix:
First Name:LATAUNYA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:359 BROOKWOOD LAKE PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39272-5648
Mailing Address - Country:US
Mailing Address - Phone:601-924-7043
Mailing Address - Fax:601-924-8633
Practice Address - Street 1:102 WOODCHASE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4113
Practice Address - Country:US
Practice Address - Phone:601-924-7043
Practice Address - Fax:601-924-8633
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist