Provider Demographics
NPI:1396200101
Name:WALLACE, LAUREL E (RN)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LAURA DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085
Mailing Address - Country:US
Mailing Address - Phone:413-562-2747
Mailing Address - Fax:
Practice Address - Street 1:50 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4127
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN121600163WP0808X
261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health