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General NPI Number Information
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NPI Number | 1831686369
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Entity Type | Individual
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Provider Name | LAURIE MEAGAN WALLACE DO
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Gender | Female
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Dates
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Enumeration Date | 04/19/2018
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 1268 NEXTON PKWY STE 104
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City | SUMMERVILLE
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State | SC
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Zip | 29486-2167
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Country | US
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Telephone | 843-212-8080
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Fax | 843-402-2681
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Provider Business Mailing Address
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Address Line | PO BOX 751649
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City | CHARLOTTE
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State | NC
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Zip | 28275-1649
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Country | US
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Telephone |
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Fax |
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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 | 2075
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 93547
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License Number State | SC
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