Provider Demographics
NPI:1952689341
Name:WALLACE, LAUREN AHLES (MS)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:AHLES
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:NICOLE
Other - Last Name:AHLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:5121 S COTTONWOOD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5701
Mailing Address - Country:US
Mailing Address - Phone:801-507-7424
Mailing Address - Fax:801-507-7494
Practice Address - Street 1:5121 S COTTONWOOD ST STE 100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-7424
Practice Address - Fax:801-507-7494
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8403569-3601170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS