Provider Demographics
NPI:1225482946
Name:WALLACE, LAUREL SLOUGH (DO)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:SLOUGH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:
Other - Last Name:SLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:13540 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2107
Mailing Address - Country:US
Mailing Address - Phone:804-739-6142
Mailing Address - Fax:
Practice Address - Street 1:13540 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2107
Practice Address - Country:US
Practice Address - Phone:804-739-6142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine