Provider Demographics
NPI:1083463947
Name:WALLACE, ANGEL SHA'MIAH (CPCT-A)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:SHA'MIAH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CPCT-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 AVENUE K
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35218-2159
Mailing Address - Country:US
Mailing Address - Phone:659-910-1100
Mailing Address - Fax:
Practice Address - Street 1:2609 AVENUE K
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35218-2159
Practice Address - Country:US
Practice Address - Phone:659-910-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPF4Q3Z3H9247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other