Provider Demographics
NPI:1699495325
Name:WALLACE, KRYSTLE (IBCLC)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16002 PHILMONT LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1619
Mailing Address - Country:US
Mailing Address - Phone:203-231-0947
Mailing Address - Fax:
Practice Address - Street 1:16002 PHILMONT LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1619
Practice Address - Country:US
Practice Address - Phone:203-231-0947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN