Provider Demographics
NPI:1871756957
Name:WALLACE, ELLEN DEANNE (PT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DEANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-2923
Mailing Address - Country:US
Mailing Address - Phone:859-737-5888
Mailing Address - Fax:
Practice Address - Street 1:404 CEDAR CT
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-2923
Practice Address - Country:US
Practice Address - Phone:859-737-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist