Provider Demographics
NPI:1922436914
Name:WALLACE, DONNETTA LYNN
Entity Type:Individual
Prefix:
First Name:DONNETTA
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNETTA
Other - Middle Name:LYNN
Other - Last Name:LUEBKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-682-1313
Mailing Address - Fax:763-581-9090
Practice Address - Street 1:1001 HART BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8929
Practice Address - Country:US
Practice Address - Phone:763-295-2921
Practice Address - Fax:763-581-9090
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 151800-9363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily