Provider Demographics
NPI:1063828184
Name:WALLACE, LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:LORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4190 LOBERG AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2652
Mailing Address - Country:US
Mailing Address - Phone:218-249-4600
Mailing Address - Fax:
Practice Address - Street 1:4190 LOBERG AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2652
Practice Address - Country:US
Practice Address - Phone:218-249-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125065769207Q00000X
MO2021034580207Q00000X
MN73123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine