Most Relevant Information
Provider Data
| NPI Number: | 1003423658 |
| Provider Name: | LISA CAROL WALLACE FNP-BC |
| Entity Type: | Individual |
| Taxonomy Code: | 363LF0000X |
| Specialty: | Nurse Practitioner |
| License Number: | A160503 |
Most Important Dates
| Enumeration Date: | 09/28/2020 |
| Last Updated: | 09/28/2020 |
Provider Practice Location
2418 180TH ST
ALLERTON
IA
500088715
Practice Location Phone/Fax
| Phone: | 6412030726 |
| Fax: |
Provider Mailing Location
2418 180TH ST
ALLERTON
IA
500088715
Provider Mailing Phone/Fax
| Phone: | 6412030726 |
| Fax: |