Individual
LAURA JEAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8600 NICOLLET AVE S, BLOOMINGTON, MN 55420-2824
(952) 541-2800
(952) 886-7015
Mailing address
8170 33RD AVE S, MINNEAPOLIS, MN 55425-4516
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
61835
MN
390200000X
Student in an Organized Health Care Education/Training Program
RS2014-0296
NM
Other
Enumeration date
04/08/2014
Last updated
03/17/2018
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