Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 3007721 | KY |
NPI | 1104178052 |
---|---|
Provider Name | Mrs. Amy M Wallace |
First Address | Lexington, KY 40536-0001 |
Second Address | Lexington, KY 40536-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2012 |
Last Update Date | 02/10/2012 |