Healthcare Provider Details

I. General information

NPI: 1669355566
Provider Name (Legal Business Name): HAILEY WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 KENTUCKY AVE
PADUCAH KY
42003-1977
US

IV. Provider business mailing address

916 KENTUCKY AVE
PADUCAH KY
42003-1977
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-9631
  • Fax: 270-442-8769
Mailing address:
  • Phone: 270-444-9631
  • Fax: 270-442-8769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number4007951
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4007951
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: