Provider Demographics
NPI:1548650617
Name:WALLACE, KATHERINE MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:HORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:2702 BETCHET LANE
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-6153
Mailing Address - Country:US
Mailing Address - Phone:334-750-1421
Mailing Address - Fax:
Practice Address - Street 1:118 ENTERPRISE CT STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9228
Practice Address - Country:US
Practice Address - Phone:706-330-1389
Practice Address - Fax:706-330-1392
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA0714020363LA2200X
GARN243697363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161276BMedicaid