Provider Demographics
NPI:1568850006
Name:WALLACE, SARAH
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18714 W 163RD TER
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-2786
Mailing Address - Country:US
Mailing Address - Phone:785-249-4676
Mailing Address - Fax:
Practice Address - Street 1:390 LIMIT ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-4525
Practice Address - Country:US
Practice Address - Phone:913-651-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS76650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily