Provider Demographics
NPI:1831578012
Name:WALLACE, KATHRYN NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 EL POMAR DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-8555
Mailing Address - Country:US
Mailing Address - Phone:805-610-0657
Mailing Address - Fax:
Practice Address - Street 1:320 ALISAL RD STE 406
Practice Address - Street 2:
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-3750
Practice Address - Country:US
Practice Address - Phone:805-688-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic