Individual
PATRICIA ANN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.T.
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
31000396A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000355350
ANTHEM ID
IN
05
—
200515660
—
IN
Enumeration date
04/06/2006
Last updated
08/05/2013
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