Provider Demographics
NPI:1447462270
Name:WALLACE, RACHEL L (ATC)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 N THAYER RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-9770
Mailing Address - Country:US
Mailing Address - Phone:419-224-7660
Mailing Address - Fax:
Practice Address - Street 1:801 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-4099
Practice Address - Country:US
Practice Address - Phone:419-222-6622
Practice Address - Fax:419-222-4069
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0008412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer