Provider Demographics
NPI:1912552035
Name:WALLACE, ASHLEY WAILES
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:WAILES
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 1:3292 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-2309
Mailing Address - Country:US
Mailing Address - Phone:562-427-2225
Mailing Address - Fax:562-427-5656
Practice Address - Street 1:3292 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-2309
Practice Address - Country:US
Practice Address - Phone:562-427-2225
Practice Address - Fax:562-427-5656
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist