Provider Demographics
NPI:1366158859
Name:WALLACE, KENORA S
Entity type:Individual
Prefix:
First Name:KENORA
Middle Name:S
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 1:2085 GOODMAN RD W STE 80
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1416
Mailing Address - Country:US
Mailing Address - Phone:662-890-0012
Mailing Address - Fax:
Practice Address - Street 1:2085 GOODMAN RD W STE 8
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1416
Practice Address - Country:US
Practice Address - Phone:662-890-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1367OtherLICENSE