Provider Demographics
NPI:1316496417
Name:WALLACE, ARI
Entity type:Individual
Prefix:MRS
First Name:ARI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ARI
Other - Middle Name:BRIANNE
Other - Last Name:FORESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:STE 508
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-886-3228
Mailing Address - Fax:904-886-3297
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:STE 508
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:904-886-3297
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist