1972044519 NPI number — MICHELLE D WALLACE

Table of content: MICHELLE D WALLACE (NPI 1972044519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972044519 NPI number — MICHELLE D WALLACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
MICHELLE
Provider Middle Name:
D
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:
1972044519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9701 APOLLO DR STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20774-4785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-985-2985
Provider Business Mailing Address Fax Number:
240-565-6034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9701 APOLLO DR STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-4785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-985-2985
Provider Business Practice Location Address Fax Number:
240-565-6034
Provider Enumeration Date:
03/15/2017

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5906592 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10085097 . This is a "CAREFIRST CHPDC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 10085097 . This is a "MEDSTAR FAMILY CHOICE OF DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 2021218766 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PDXGR13328727 . This is a "AETNA BETTER HEALTH OF MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 10085097 . This is a "MEDSTAR FAMILY CHOICE OF MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 60402094 . This is a "AMERI HEALTH CARITAS DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com