Provider Demographics
NPI:1942223474
Name:WALLACE, WENDY (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 EAST MARSHALL ST
Mailing Address - Street 2:SUITE 301-307
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380
Mailing Address - Country:US
Mailing Address - Phone:610-429-1100
Mailing Address - Fax:610-429-4848
Practice Address - Street 1:795 EAST MARSHALL ST
Practice Address - Street 2:SUITE 301-307
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380
Practice Address - Country:US
Practice Address - Phone:610-429-1100
Practice Address - Fax:610-429-4848
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-006612-L208000000X
DEC2-0003778208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE39446Medicare UPIN
PA060969Medicare ID - Type Unspecified