Provider Demographics
NPI:1548665037
Name:WALLACE, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
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 1:1115 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-3425
Mailing Address - Country:US
Mailing Address - Phone:330-809-7073
Mailing Address - Fax:
Practice Address - Street 1:1115 13TH ST SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-3425
Practice Address - Country:US
Practice Address - Phone:330-809-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor