Healthcare Provider Details

I. General information

NPI: 1427609759
Provider Name (Legal Business Name): LORI SUE WALLACE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HEALTH PARTNERS CIR
MOUNT ORAB OH
45154-8610
US

IV. Provider business mailing address

424 WARDS CORNER RD STE 200
LOVELAND OH
45140-6966
US

V. Phone/Fax

Practice location:
  • Phone: 937-444-2514
  • Fax: 937-444-4818
Mailing address:
  • Phone: 513-707-4041
  • Fax: 513-576-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.025720
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: