Provider Demographics
NPI:1922985373
Name:WALLACE, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
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 1:2301 SW ORALABOR RD TRLR 79
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-9813
Mailing Address - Country:US
Mailing Address - Phone:641-777-8050
Mailing Address - Fax:
Practice Address - Street 1:2507 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-4505
Practice Address - Country:US
Practice Address - Phone:515-271-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program