# KATHRYN MARY WALLACE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1407965320
- **Gender:** F
- **Credential:** APRN, BC

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363L00000X | Nurse Practitioner | 71000473A | IN | Yes |

## Other

- **Enumeration date:** 08/30/2006
- **Last updated:** 09/17/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200056120A | — | IN |
| 01 | — | 500004228 | RAILROAD MEDICARE | IN |