Provider Demographics
NPI:1912942954
Name:WALLACE, KENDRA (PT)
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 HENDERSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-8080
Mailing Address - Country:US
Mailing Address - Phone:770-386-6300
Mailing Address - Fax:770-382-0791
Practice Address - Street 1:695 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3738
Practice Address - Country:US
Practice Address - Phone:770-386-6300
Practice Address - Fax:770-382-0791
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008410225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist