Provider Demographics
NPI:1043305444
Name:WALLACE, LORRIE KAY (ARNP, LAC)
Entity type:Individual
Prefix:
First Name:LORRIE
Middle Name:KAY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:ARNP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31927
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-0027
Mailing Address - Country:US
Mailing Address - Phone:206-436-9772
Mailing Address - Fax:
Practice Address - Street 1:2319 N 45TH ST
Practice Address - Street 2:SUITE #201
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6982
Practice Address - Country:US
Practice Address - Phone:206-436-9772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001964363LF0000X
WAAC60134530171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171100000XOther Service ProvidersAcupuncturist