# LAURY M WALLACE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1205343845
- **Gender:** F
- **Credential:** NP

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0000X | Adolescent Medicine (Family Medicine) Physician | 71007724A | IN | — |
| 207QA0505X | Adult Medicine Physician | 71007724A | IN | Yes |
| 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