Basic Information
| Provider Information | |||||||||
| NPI: | 1790249100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | KAITLYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3319 E FOREST LAKE RD | ||||||||
| Address2: | |||||||||
| City: | ACAMPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952209573 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S AVE K | ||||||||
| Address2: | STATION 3, SHROC | ||||||||
| City: | PORTALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755622156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2019 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.