Provider Demographics
NPI:1528731247
Name:WALLACE, TONYA MICHELLE
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:MICHELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2206
Mailing Address - Country:US
Mailing Address - Phone:937-239-0039
Mailing Address - Fax:
Practice Address - Street 1:37 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-2206
Practice Address - Country:US
Practice Address - Phone:937-239-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)