Provider Demographics
NPI:1255627469
Name:WALLACE, COLLEEN MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MICHELLE
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 1:14113 BALTIMORE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5073
Mailing Address - Country:US
Mailing Address - Phone:240-360-5723
Mailing Address - Fax:
Practice Address - Street 1:14113 BALTIMORE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5073
Practice Address - Country:US
Practice Address - Phone:240-360-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD78050208M00000X, 208000000X
VA0116023955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty