Individual
LAUREL LYNN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
606 MEDICAL PKY, ENTERPRISE, OR 97828
(541) 426-4524
Mailing address
405 NW 2ND ST, ENTERPRISE, OR 97828-1014
(541) 398-8671
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
175T00000X
Peer Specialist
Primary
—
—
Other
Enumeration date
04/13/2022
Last updated
08/08/2022
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