Healthcare Provider Details

I. General information

NPI: 1790121689
Provider Name (Legal Business Name): LACEY BETH WALLS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY BETH ELWYN

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 07/21/2022
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 PENNY LN
CONCORD NC
28025-1221
US

IV. Provider business mailing address

335 PENNY LN
CONCORD NC
28025-1221
US

V. Phone/Fax

Practice location:
  • Phone: 704-784-5901
  • Fax: 704-721-0413
Mailing address:
  • Phone: 704-784-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number276541
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS14737
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2018-01570
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: