Provider Demographics
NPI:1629948740
Name:WALLACE, LYNDI
Entity type:Individual
Prefix:
First Name:LYNDI
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 1:1175 LEWIS OAK RD
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-9306
Mailing Address - Country:US
Mailing Address - Phone:801-815-0598
Mailing Address - Fax:530-869-5315
Practice Address - Street 1:1175 LEWIS OAK RD
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-9306
Practice Address - Country:US
Practice Address - Phone:530-635-5742
Practice Address - Fax:530-869-5315
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-05
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty