Provider Demographics
NPI:1841862059
Name:WALLACE, PEGGY LYNN (APRN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 E 1675 N
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3379
Mailing Address - Country:US
Mailing Address - Phone:801-675-6624
Mailing Address - Fax:
Practice Address - Street 1:2132 N 1700 W, STE 100
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7059
Practice Address - Country:US
Practice Address - Phone:801-807-7900
Practice Address - Fax:801-807-7904
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114266-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner