Provider Demographics
NPI:1265737753
Name:WALLACE, LAURA ANN (APN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:301 N HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:PILOT KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:63663-7862
Mailing Address - Country:US
Mailing Address - Phone:573-546-8036
Mailing Address - Fax:573-546-8067
Practice Address - Street 1:301 N HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:PILOT KNOB
Practice Address - State:MO
Practice Address - Zip Code:63663-7862
Practice Address - Country:US
Practice Address - Phone:573-546-8036
Practice Address - Fax:573-546-8067
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010037004363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care