Basic Information
| Provider Information | |||||||||
| NPI: | 1033542170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2156 CHAMBER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2156 CHAMBER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3008278 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.