Provider Demographics
NPI:1699594788
Name:WALLACE, LAURA (RN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:WALLACE
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 1:124 DONNA LN
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2729
Mailing Address - Country:US
Mailing Address - Phone:423-579-4539
Mailing Address - Fax:
Practice Address - Street 1:710 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3143
Practice Address - Country:US
Practice Address - Phone:865-425-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN275332163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse