Individual
STACY LEA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NCC
Contact information
Practice address
540 ILLINOIS ST, PAWNEE, OK 74058-2036
(918) 762-1045
Mailing address
540 ILLINOIS ST, PAWNEE, OK 74058-2036
(918) 762-1045
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Enumeration date
08/15/2013
Last updated
08/15/2013
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