Provider Demographics
NPI:1205570660
Name:WALLACE, HATTIE (PTA)
Entity type:Individual
Prefix:
First Name:HATTIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 NW MARKET STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1148 NW MARKET STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102
Practice Address - Country:US
Practice Address - Phone:206-860-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant