1780807727 NPI number — MRS. STEPHANIE DAWN WALLACE SW

Table of content: MRS. STEPHANIE DAWN WALLACE SW (NPI 1780807727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780807727 NPI number — MRS. STEPHANIE DAWN WALLACE SW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
STEPHANIE
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SW
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:
1780807727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 SE WHISPERING WILLOWS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27406-8599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-641-6370
Provider Business Mailing Address Fax Number:
336-641-6693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1203 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27405-6910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-641-6370
Provider Business Practice Location Address Fax Number:
336-641-6693
Provider Enumeration Date:
04/10/2007

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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