Provider Demographics
NPI:1922434091
Name:WALLACE, PATRICIA J
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
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 1:1 CHESTERFIELD MALL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4807
Mailing Address - Country:US
Mailing Address - Phone:636-536-4660
Mailing Address - Fax:636-532-4667
Practice Address - Street 1:1 CHESTERFIELD MALL
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4807
Practice Address - Country:US
Practice Address - Phone:636-536-4660
Practice Address - Fax:636-532-4667
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013004502237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013004502OtherHEARING AID DISPENSER LICENSE