Healthcare Provider Details

I. General information

NPI: 1780483941
Provider Name (Legal Business Name): ELIZABETH LEE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 MCCARTY LN LAFAYETTE, IN 47905
LAFAYETTE IN
47905
US

IV. Provider business mailing address

3001 BURTON RD
WESTPOINT IN
47992-9339
US

V. Phone/Fax

Practice location:
  • Phone: 765-730-5662
  • Fax:
Mailing address:
  • Phone: 765-730-5662
  • Fax: 765-730-5662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28263926A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: