Provider Demographics
NPI:1396921722
Name:WALLACE, TRISTIN HC (ND)
Entity type:Individual
Prefix:DR
First Name:TRISTIN
Middle Name:HC
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14201 NE 20TH AVE
Mailing Address - Street 2:SUITE 1102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6410
Mailing Address - Country:US
Mailing Address - Phone:360-882-7373
Mailing Address - Fax:360-882-7673
Practice Address - Street 1:14201 NE 20TH AVE
Practice Address - Street 2:SUITE 1102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6410
Practice Address - Country:US
Practice Address - Phone:360-882-7373
Practice Address - Fax:360-882-7673
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT 60083023175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath