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General NPI Number Information
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NPI Number | 1679839534
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Entity Type | Individual
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Provider Name | HAILY WALLACE MD
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Gender | Female
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Dates
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Enumeration Date | 04/05/2012
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Last Update Date | 06/18/2015
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Provider Practice Location Address
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Address Line | 402 E MIEL DE LUNA AVE PMG AT DR DAN C TRIGG MEMORIAL HOSPITAL
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City | TUCUMCARI
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State | NM
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Zip | 88401-3828
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Country | US
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Telephone | 575-461-7100
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Fax | 575-461-7101
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Provider Business Mailing Address
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Address Line | PO BOX 26666 PHS PROVIDER ENROLLMENT
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City | ALBUQUERQUE
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State | NM
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Zip | 87125-6666
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Country | US
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Telephone | 505-923-6770
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Fax | 505-923-5354
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD2014-0895
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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