Provider Demographics
NPI:1932220225
Name:WALLACE, ELIZABETH SPAGAT (ND,LAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SPAGAT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ND,LAC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SPAGAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2024 SE CLINTON ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:503-242-1212
Mailing Address - Fax:503-236-7637
Practice Address - Street 1:2024 SE CLINTON ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-242-1212
Practice Address - Fax:503-236-7637
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0020610171100000X
OR1283175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist