Individual
ALLISON WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
453 LIDO BLVD, LIDO BEACH, NY 11561-5107
(516) 680-3741
Mailing address
453 LIDO BLVD, LIDO BEACH, NY 11561-5107
(516) 680-3741
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
606700121
NY
Other
Enumeration date
05/18/2015
Last updated
05/18/2015
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