Individual
TRACY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
15400 W MCNICHOLS RD, DETROIT, MI 48235-3724
(313) 732-8272
Mailing address
4779 GLENDALE, DETROIT, MI 48238
Taxonomy
Speciality
Code
Description
License number
State
163WA2000X
Administrator Registered Nurse
Primary
4704197701
MI
Other
Enumeration date
04/16/2013
Last updated
04/16/2013
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