Individual
JASMINE RENEE' WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5535 NW CACHE RD, APT:8G, LAWTON, OK 73505-3336
(580) 713-9316
Mailing address
5535 NW CACHE RD, APT:8G, LAWTON, OK 73505-3336
(580) 713-9316
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Enumeration date
05/24/2013
Last updated
05/24/2013
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