Healthcare Provider Details

I. General information

NPI: 1144262197
Provider Name (Legal Business Name): LAURA WALLACE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PINELLAS ST SUITE #400
CLEARWATER FL
33756-3354
US

IV. Provider business mailing address

1717 TALL PINE CIR
SAFETY HARBOR FL
34695-5204
US

V. Phone/Fax

Practice location:
  • Phone: 727-445-1911
  • Fax: 727-445-1986
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2529872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: