Provider Demographics
NPI:1033200431
Name:WALLACE, CATHERINE (NP)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12339 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8148
Mailing Address - Country:US
Mailing Address - Phone:515-263-9107
Mailing Address - Fax:515-265-9888
Practice Address - Street 1:12339 STRATFORD DR
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8148
Practice Address - Country:US
Practice Address - Phone:515-263-9107
Practice Address - Fax:515-265-9888
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA106126363LN0000X, 363LP1700X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0104OtherJOHN DEERE
IA1033200431Medicaid
IAIA0104OtherJOHN DEERE