Provider Demographics
NPI:1417785296
Name:WALLIS, TONI (DC)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:DANIELLE BLUE
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3204 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-6647
Mailing Address - Country:US
Mailing Address - Phone:903-343-2654
Mailing Address - Fax:
Practice Address - Street 1:1000 FIANNA WAY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-8285
Practice Address - Country:US
Practice Address - Phone:479-222-4698
Practice Address - Fax:479-308-0264
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor