Individual
NANCY ANN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
2909 FRIENDSHIP RD, PARAGOULD, AR 72450-7548
(601) 624-2618
Mailing address
2909 FRIENDSHIP RD, PARAGOULD, AR 72450-7548
(601) 624-2618
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OT1220
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
194418721
—
AR
Enumeration date
12/10/2012
Last updated
12/10/2012
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