Provider Demographics
NPI:1568232676
Name:WALLACE, MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7547
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE STE 231
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3099
Practice Address - Country:US
Practice Address - Phone:317-621-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014833A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner