Provider Demographics
NPI:1679047005
Name:WALLACE, LAURA J (CNM)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:115 EAGLE SPRING DR STE A200
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6486
Mailing Address - Country:US
Mailing Address - Phone:770-474-0064
Mailing Address - Fax:770-474-2998
Practice Address - Street 1:115 EAGLE SPRING DR STE A200
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6486
Practice Address - Country:US
Practice Address - Phone:770-474-0064
Practice Address - Fax:770-474-2998
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN067198367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife