Provider Demographics
NPI:1518584762
Name:WALLACE, BRIDGET QUINN (TEACHER)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:QUINN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 STEVEN PL APT 3C
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2504
Mailing Address - Country:US
Mailing Address - Phone:631-804-8184
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C-103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1208156246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other