Individual
TARA WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT, MMP
Contact information
Practice address
2633 BABBLE CREEK LN, O FALLON, MO 63368-8338
(636) 577-1216
(636) 294-0837
Mailing address
2633 BABBLE CREEK LN, O FALLON, MO 63368-8338
(636) 577-1216
(636) 294-0837
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
2001032642
MO
Other
Enumeration date
06/18/2013
Last updated
06/18/2013
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