Wallace, Theresa A

Wallace, Theresa A is an individual health care provider with primary practice located at 1075 Mason Ave , Daytona Beach FL 32117-4611. She recently has 2 registered licenses in different health care specialties including Respiratory, Developmental, Rehabilitative and Restorative Service Providers / Athletic Trainer, Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant. Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant is her primary health care specialty. Wallace, Theresa A can be contacted via phone (386) 255-4596.

Contact Information

Primary practice address
1075 Mason Ave Daytona Beach FL 32117-4611
Phone: (386) 255-4596
Fax: (386) 258-3561
Website:
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Health care specialties

SpecialtyCodeLicense #State
Respiratory, Developmental, Rehabilitative and Restorative Service Providers / Athletic Trainer 2255A2300X AL2836 Florida
Physician Assistants & Advanced Practice Nursing Providers / Physician Assistant 363A00000X PA9113017 Florida

Profile Details

NPI number 1437404548
LBN Legal business name Wallace, Theresa A
Credentials PA-C, ATC
Entity Individual
Sole proprietor 1 No
Enumeration date Jul 16th, 2012
Last updated Jul 6th, 2022 - about 3 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1437404548 NPPES
Florida MEDICAID 105958900

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