Provider Demographics
NPI:1912581158
Name:WALLACE, CYNTHIA (LAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4356 BONNEY RD
Mailing Address - Street 2:BUILDING 2 SUITE 103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1200
Mailing Address - Country:US
Mailing Address - Phone:757-497-3111
Mailing Address - Fax:
Practice Address - Street 1:4356 BONNEY RD
Practice Address - Street 2:BUILDING 2 SUITE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1200
Practice Address - Country:US
Practice Address - Phone:757-497-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000216171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist