Basic Information
| Provider Information | |||||||||
| NPI: | 1194764647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 608 UNION CHAPEL RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468459357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604982020 | ||||||||
| FaxNumber: | 2604982030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1355 MARINERS DR | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465827145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743720000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01061919A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.