Provider Demographics
NPI:1780483941
Name:WALLACE, ELIZABETH LEE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 BURTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTPOINT
Mailing Address - State:IN
Mailing Address - Zip Code:47992-9339
Mailing Address - Country:US
Mailing Address - Phone:765-730-5662
Mailing Address - Fax:765-730-5662
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:LAFAYETTE, IN 47905
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-730-5662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28263926A163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency