Provider Demographics
NPI:1740252576
Name:WALLACE, CELESTE NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DR
Mailing Address - Street 2:SUITE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7008
Mailing Address - Country:US
Mailing Address - Phone:336-802-2536
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:802 GREEN VALLEY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7041
Practice Address - Country:US
Practice Address - Phone:336-802-2536
Practice Address - Fax:336-802-2534
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34--008564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2583520Medicaid
OHW4166381Medicare ID - Type Unspecified
OH2583520Medicaid