Basic Information
| Provider Information | |||||||||
| NPI: | 1750560579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | GENEVIEVE | ||||||||
| MiddleName: | REBECCA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | JENNY | ||||||||
| OtherMiddleName: | REBECCA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1056 S 88TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800279460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034426647 | ||||||||
| FaxNumber: | 3034422696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1056 S 88TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800279460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034426647 | ||||||||
| FaxNumber: | 3034422696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | 57122 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207N00000X | DR.0057122 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.