Provider Demographics
NPI:1487438032
Name:WALLACE, TAWNI (AUD)
Entity type:Individual
Prefix:
First Name:TAWNI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 THE WOODS DR APT 234
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-4634
Mailing Address - Country:US
Mailing Address - Phone:818-439-8490
Mailing Address - Fax:
Practice Address - Street 1:5855 SILVER CREEK VALLEY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138-1059
Practice Address - Country:US
Practice Address - Phone:408-574-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13548114-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist