Healthcare Provider Details

I. General information

NPI: 1477484632
Provider Name (Legal Business Name): DEDRA DANYALE WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 JEFFERSON ST
LAUREL MS
39440-4355
US

IV. Provider business mailing address

3640 OLD BAY SPRINGS RD
LAUREL MS
39440-1461
US

V. Phone/Fax

Practice location:
  • Phone: 601-426-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number100297090
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: