Provider Demographics
NPI:1447718077
Name:WALLACE, MELANIE (MED)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 WESTMORELAND DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-5323
Mailing Address - Country:US
Mailing Address - Phone:336-707-3370
Mailing Address - Fax:
Practice Address - Street 1:7700 US HIGHWAY 158
Practice Address - Street 2:
Practice Address - City:STOKESDALE
Practice Address - State:NC
Practice Address - Zip Code:27357-9346
Practice Address - Country:US
Practice Address - Phone:336-643-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11874235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist