Provider Demographics
NPI:1790121689
Name:WALLS, LACEY BETH (DO)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:BETH
Last Name:WALLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:BETH
Other - Last Name:ELWYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:335 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1221
Mailing Address - Country:US
Mailing Address - Phone:704-784-5901
Mailing Address - Fax:
Practice Address - Street 1:335 PENNY LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1221
Practice Address - Country:US
Practice Address - Phone:704-784-5901
Practice Address - Fax:704-721-0413
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276541207N00000X
FLOS14737207N00000X
NC2018-01570207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology