Provider Demographics
NPI:1215702683
Name:WALLACE, LAURA (CNP, DNP-FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNP, DNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13060 42ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473-2495
Mailing Address - Country:US
Mailing Address - Phone:763-291-5193
Mailing Address - Fax:
Practice Address - Street 1:14040 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9612
Practice Address - Country:US
Practice Address - Phone:763-488-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily