Provider Demographics
NPI:1972953172
Name:WALLACE, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
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 1:8133 FARM CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7131
Mailing Address - Country:US
Mailing Address - Phone:715-347-2419
Mailing Address - Fax:
Practice Address - Street 1:8133 FARM CROSSING CIR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7131
Practice Address - Country:US
Practice Address - Phone:715-347-2419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker