Healthcare Provider Details

I. General information

NPI: 1841619848
Provider Name (Legal Business Name): LAURA JEAN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NICOLLET AVE S
BLOOMINGTON MN
55420-2824
US

IV. Provider business mailing address

8170 33RD AVE S
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-541-2800
  • Fax: 952-886-7015
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2014-0296
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61835
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: