Provider Demographics
NPI:1396155594
Name:WALLIS, LAURIE ELIZABETH (RN)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ELIZABETH
Last Name:WALLIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 TOWN & COUNTRY BLVD.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526
Mailing Address - Country:US
Mailing Address - Phone:925-628-8165
Mailing Address - Fax:925-838-7618
Practice Address - Street 1:145 TOWN & COUNTRY BLVD.
Practice Address - Street 2:SUITE 106
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526
Practice Address - Country:US
Practice Address - Phone:925-628-8165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA825169163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse