Provider Demographics
NPI:1205343845
Name:WALLACE, LAURY M (NP)
Entity type:Individual
Prefix:
First Name:LAURY
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16731 GAITHER BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-4421
Mailing Address - Country:US
Mailing Address - Phone:812-239-3771
Mailing Address - Fax:
Practice Address - Street 1:16731 GAITHER BLVD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-4607
Practice Address - Country:US
Practice Address - Phone:317-561-6840
Practice Address - Fax:812-239-3771
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007724A207QA0000X, 207QG0300X, 207QH0002X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine