1811210495 NPI number — MRS. JUDITH MARGARET CAMPBELL WALLACE M.S.

Table of content: MRS. JUDITH MARGARET CAMPBELL WALLACE M.S. (NPI 1811210495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811210495 NPI number — MRS. JUDITH MARGARET CAMPBELL WALLACE M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL WALLACE
Provider First Name:
JUDITH
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLACE
Provider Other First Name:
MARGARET
Provider Other Middle Name:
CAMPBELL
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1811210495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 S. PERIMETER PARK DRIVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37211-4143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-525-0391
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6110 SHALLOWFORD RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-1894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-509-4123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2010

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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