Individual
STEPHANIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
C.R.N.A.
Contact information
Practice address
600 N WOLFE ST, BALTIMORE, MD 21287-0005
(410) 955-6353
Mailing address
PO BOX 64382, BALTIMORE, MD 21264-4382
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R039710
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110302400
—
MD
Enumeration date
06/22/2006
Last updated
07/08/2007
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