Healthcare Provider Details

I. General information

NPI: 1215702683
Provider Name (Legal Business Name): LAURA WALLACE CNP, DNP-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 NORTHDALE BLVD
ROGERS MN
55374-9612
US

IV. Provider business mailing address

13060 42ND AVE SW
PILLAGER MN
56473-2495
US

V. Phone/Fax

Practice location:
  • Phone: 763-488-4100
  • Fax:
Mailing address:
  • Phone: 763-291-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10747
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: