Provider Demographics
NPI:1902611882
Name:WALLACE, MATTHEW RICHARD (DNP, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 LAKE PARK RD APT 715
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-6600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0007
Practice Address - Country:US
Practice Address - Phone:859-562-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4044992363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health