=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669355566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAILEY WALLACE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2025
-----------------------------------------------------
Last Update Date | 07/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 KENTUCKY AVE
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-444-9631
-----------------------------------------------------
Fax | 270-442-8769
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 KENTUCKY AVE
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-444-9631
-----------------------------------------------------
Fax | 270-442-8769
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0901X
-----------------------------------------------------
Taxonomy Name | Public Health & General Preventive Medicine Physician
-----------------------------------------------------
License Number | 4007951
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Nurse Practitioner
-----------------------------------------------------
License Number | 4007951
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------