Healthcare Provider Details

I. General information

NPI: 1881337319
Provider Name (Legal Business Name): LAUREL LYNN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 MEDICAL PKY
ENTERPRISE OR
97828
US

IV. Provider business mailing address

405 NW 2ND ST
ENTERPRISE OR
97828-1014
US

V. Phone/Fax

Practice location:
  • Phone: 541-426-4524
  • Fax:
Mailing address:
  • Phone: 541-398-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: