Individual
KACIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.S., PA-C
Contact information
Practice address
22101 MOROSS RD, DETROIT, MI 48236-2148
(313) 343-4000
Mailing address
226 WIMPOLE DR, ROCHESTER HILLS, MI 48309-2148
(248) 720-8197
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1151843
MI
Other
Enumeration date
05/17/2018
Last updated
09/15/2019
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