Provider Demographics
NPI:1245124270
Name:WALLACE, MELISSA MARIE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
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 1:2797 W 21ST LN
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6059
Mailing Address - Country:US
Mailing Address - Phone:928-386-0844
Mailing Address - Fax:
Practice Address - Street 1:2797 W 21ST LN
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6059
Practice Address - Country:US
Practice Address - Phone:928-386-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ780385HR2065X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child