Individual
CYNTHIA ELAINE FAY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1115 BALL AVE NE, GRAND RAPIDS, MI 49505-5904
(616) 456-6571
Mailing address
1115 BALL AVE NE, GRAND RAPIDS, MI 49505-5904
(616) 456-6571
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
MI
Other
Enumeration date
11/17/2025
Last updated
12/09/2025
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