Individual
KIMBERLY LANE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP-C
Contact information
Practice address
3535 PENTAGON BLVD, BEAVERCREEK, OH 45431-1705
(937) 702-4000
Mailing address
935 SALEM ST, BROOKVILLE, OH 45309-8225
(937) 344-5173
Taxonomy
Speciality
Code
Description
License number
State
363LP2300X
Primary Care Nurse Practitioner
Primary
APRN.CNP.0032777
OH
Other
Enumeration date
12/06/2022
Last updated
12/06/2022
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