Individual
LISA MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
2401 W UNIVERSITY AVE, MUNCIE, IN 47303-3428
(765) 281-2030
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
71003281A
IN
363LA2200X
Adult Health Nurse Practitioner
Primary
71003281A
IN
364SX0200X
Oncology Clinical Nurse Specialist
71003281A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00000932255
ANTHEM
IN
05
—
201000070
—
IN
Enumeration date
10/06/2010
Last updated
10/16/2025
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