Provider Demographics
NPI:1033200431
Name:WALLACE, CATHERINE (NP)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2316
Mailing Address - Country:US
Mailing Address - Phone:515-263-2600
Mailing Address - Fax:515-263-2620
Practice Address - Street 1:1250 E 9TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2316
Practice Address - Country:US
Practice Address - Phone:515-263-2600
Practice Address - Fax:515-263-2620
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA106126363LN0000X, 363LP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1033200431Medicaid
IAIA0104OtherJOHN DEERE
IAIA0104OtherJOHN DEERE