Provider Demographics
NPI:1366018012
Name:WALLACE, LACIE VICTORIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LACIE
Middle Name:VICTORIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVENUE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:843-792-3451
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVENUE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:704-241-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL86050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine