{
"Npi": {
"NPI": "1780483941",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "WALLACE",
"FirstName": "ELIZABETH",
"MiddleName": "LEE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3001 BURTON RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WESTPOINT",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "47992-9339",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "765-730-5662",
"MailingAddressFaxNumber": "765-730-5662",
"FirstLinePracticeLocationAddress": "5165 MCCARTY LN",
"SecondLinePracticeLocationAddress": "LAFAYETTE, IN 47905",
"PracticeLocationAddressCityName": "LAFAYETTE",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "47905",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "765-730-5662",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "03/11/2025",
"LastUpdateDate": "03/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "163WE0003X",
"TaxonomyName": "Emergency Registered Nurse",
"LicenseNumber": "28263926A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}