Provider Demographics
NPI:1447953021
Name:WALLACE, TERRIELLE
Entity type:Individual
Prefix:
First Name:TERRIELLE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 2668 3839 MCKINNEY AVENUE
Mailing Address - Street 2:SUITE 155
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3839 MCKINNEY AVE STE 155
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1488
Practice Address - Country:US
Practice Address - Phone:469-227-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy