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Individual
LAURY M WALLACE
Active
Individual
LAURY M WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Taxonomy
Speciality
Code
Description
License number
State
207QA0000X
Adolescent Medicine (Family Medicine) Physician
71007724A
IN
207QA0505X
Adult Medicine Physician
Primary
71007724A
IN
207QG0300X
Geriatric Medicine (Family Medicine) Physician
71007724A
IN
207QH0002X
Hospice and Palliative Medicine (Family Medicine) Physician
71007724A
IN
Other
Enumeration date
01/04/2018
Last updated
10/06/2026
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