| NPI | 1346676988 |
|---|---|
| Former Name | AVIVA ADOLPHE WALLACE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: PA OS019743) |
| Additional Taxonomies | 208600000X Surgery (Licence: NC 2018-00575) |
| 208600000X Surgery (Licence: VT 032.0133820) | |
| Enumeration Date | 2013-09-15 |
| Last Update Date | 2019-11-05 |