Provider Demographics
NPI:1336663194
Name:WALLACE, KARLEN MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KARLEN
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:AIRWAY HEIGHTS
Mailing Address - State:WA
Mailing Address - Zip Code:99001-5291
Mailing Address - Country:US
Mailing Address - Phone:304-231-4162
Mailing Address - Fax:
Practice Address - Street 1:6025 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-7674
Practice Address - Country:US
Practice Address - Phone:509-326-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60707760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist