Provider Demographics
NPI:1932852423
Name:WALLACE, BRENDAN KIELY
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:KIELY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13080 MINDANAO WAY APT 91
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-8740
Mailing Address - Country:US
Mailing Address - Phone:585-797-5627
Mailing Address - Fax:
Practice Address - Street 1:600 N. WOLFE STREET
Practice Address - Street 2:MARBURG 144
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287
Practice Address - Country:US
Practice Address - Phone:410-955-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program