Provider Demographics
NPI:1972044519
Name:WALLACE, MICHELLE D
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
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 1:9701 APOLLO DR STE 105
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4785
Mailing Address - Country:US
Mailing Address - Phone:301-985-2985
Mailing Address - Fax:240-565-6034
Practice Address - Street 1:9701 APOLLO DR STE 105
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4785
Practice Address - Country:US
Practice Address - Phone:301-985-2985
Practice Address - Fax:240-565-6034
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5906592OtherCIGNA
DC10085097OtherCAREFIRST CHPDC
DC10085097OtherMEDSTAR FAMILY CHOICE OF DC
VA2021218766Medicaid
MDPDXGR13328727OtherAETNA BETTER HEALTH OF MARYLAND
MD10085097OtherMEDSTAR FAMILY CHOICE OF MD
DC60402094OtherAMERI HEALTH CARITAS DC