Individual
EBONIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
140 S BEACH ST STE 310, DAYTONA BEACH, FL 32114-4409
(386) 898-6040
(386) 256-2320
Mailing address
140 S BEACH ST, DAYTONA BEACH, FL 32114-4472
(386) 898-6040
(386) 256-2320
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
019212700
—
FL
Enumeration date
10/20/2016
Last updated
02/18/2021
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