Provider Demographics
NPI:1336497460
Name:WALLACE, MARY (DC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:6093 SABAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7139
Mailing Address - Country:US
Mailing Address - Phone:603-721-2162
Mailing Address - Fax:
Practice Address - Street 1:292 STATE ROUTE 101 UNIT K2
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-1730
Practice Address - Country:US
Practice Address - Phone:603-721-2162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor