Individual
NICOLE L WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
I.S.
Contact information
Practice address
2185 KORO AVE, IDAHO FALLS, ID 83404-6226
(520) 233-3382
Mailing address
2185 KORO AVE, IDAHO FALLS, ID 83404-6226
(520) 233-3382
Taxonomy
Speciality
Code
Description
License number
State
106E00000X
Assistant Behavior Analyst
Primary
—
—
Other
Enumeration date
08/14/2024
Last updated
08/14/2024
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