Provider Demographics
NPI:1669877957
Name:WALLACE, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
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 1:11845 STERLING HWY
Mailing Address - Street 2:
Mailing Address - City:NINILCHIK
Mailing Address - State:AK
Mailing Address - Zip Code:99639-9769
Mailing Address - Country:US
Mailing Address - Phone:907-567-3990
Mailing Address - Fax:907-567-3990
Practice Address - Street 1:11845 STERLING HWY
Practice Address - Street 2:
Practice Address - City:NINILCHIK
Practice Address - State:AK
Practice Address - Zip Code:99639-9769
Practice Address - Country:US
Practice Address - Phone:907-567-3990
Practice Address - Fax:907-567-3990
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator