Provider Demographics
NPI:1033542170
Name:WALLACE, LAURIE A (APRN)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 CHAMBER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1669
Mailing Address - Country:US
Mailing Address - Phone:859-341-6255
Mailing Address - Fax:859-547-1197
Practice Address - Street 1:2156 CHAMBER CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE PARK
Practice Address - State:KY
Practice Address - Zip Code:41017-1669
Practice Address - Country:US
Practice Address - Phone:859-341-6255
Practice Address - Fax:859-547-1197
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008278363LF0000X, 363L00000X
KY1117583163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse