1366098642 NPI number — MAGGIE MAE WALLACE

Table of content: MAGGIE MAE WALLACE (NPI 1366098642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366098642 NPI number — MAGGIE MAE WALLACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
MAGGIE
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366098642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 OFFICE PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULF SHORES
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36542-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-968-7379
Provider Business Mailing Address Fax Number:
251-968-5960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 OFFICE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULF SHORES
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36542-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-968-7379
Provider Business Practice Location Address Fax Number:
251-968-5960
Provider Enumeration Date:
08/13/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  8373 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 1-182953 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)