Basic Information
| Provider Information | |||||||||
| NPI: | 1770099244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DEVON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226016365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406652750 | ||||||||
| FaxNumber: | 5406652749 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 14TH ST | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406363500 | ||||||||
| FaxNumber: | 5406363502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305211669 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.