Provider Demographics
NPI:1306256201
Name:WALLACE, MARILYN G (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2707 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9458
Mailing Address - Country:US
Mailing Address - Phone:919-735-9146
Mailing Address - Fax:919-735-0582
Practice Address - Street 1:2707 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9458
Practice Address - Country:US
Practice Address - Phone:919-735-9146
Practice Address - Fax:919-735-0582
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC33514207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology