Provider Demographics
NPI:1770704306
Name:WALLACE, LAURIE ANN (MPT, ATC)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LOMA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-6005
Mailing Address - Country:US
Mailing Address - Phone:772-321-4992
Mailing Address - Fax:
Practice Address - Street 1:130 LOMA VISTA DR
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010
Practice Address - Country:US
Practice Address - Phone:772-321-4992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18527225100000X
FLAL6172255A2300X, 2255A2300X
CA42268225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA169177Medicare PIN
CACA169178Medicare PIN
CACP932Medicare PIN
CAZZZ06873ZMedicare PIN