Individual
KACEY L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
1000 W CHOCTAW AVE STE 9, CHICKASHA, OK 73018
(405) 544-2940
(405) 337-9632
Mailing address
1000 W CHOCTAW AVE STE 9, CHICKASHA, OK 73018
(405) 544-2940
(405) 337-9632
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4339
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200077860A
—
OK
01
—
P00331218
MEDICARE RAIL ROAD
OK
Enumeration date
07/24/2006
Last updated
11/24/2023
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