Provider Demographics
NPI:1700157781
Name:WALLACE, NANCI (LMT)
Entity Type:Individual
Prefix:
First Name:NANCI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 SCARLET SAGE RD SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6488
Mailing Address - Country:US
Mailing Address - Phone:505-916-1233
Mailing Address - Fax:
Practice Address - Street 1:2670 SCARLET SAGE RD SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6488
Practice Address - Country:US
Practice Address - Phone:505-916-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8567172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist