Provider Demographics
NPI:1831686369
Name:WALLACE, LAURIE MEAGAN (DO)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:MEAGAN
Last Name:WALLACE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1268 NEXTON PKWY STE 104
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2167
Practice Address - Country:US
Practice Address - Phone:843-212-8080
Practice Address - Fax:843-402-2681
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2075207Q00000X
SC93547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine