Provider Demographics
NPI:1396118808
Name:WALLACE, MARZETTE
Entity type:Individual
Prefix:
First Name:MARZETTE
Middle Name:
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 1:6103 N MERIDIAN AVE
Mailing Address - Street 2:APT 114
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-1255
Mailing Address - Country:US
Mailing Address - Phone:405-635-7512
Mailing Address - Fax:405-225-7326
Practice Address - Street 1:1330 N CLASSEN BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6835
Practice Address - Country:US
Practice Address - Phone:405-694-4053
Practice Address - Fax:405-225-7326
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management