Basic Information
| Provider Information | |||||||||
| NPI: | 1033186911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1079 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708270353 | ||||||||
| FaxNumber: | 2708274966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1284 US HIGHWAY 60 W | ||||||||
| Address2: | |||||||||
| City: | MORGANFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424376236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703892323 | ||||||||
| FaxNumber: | 2703890526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22551 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64225519 | 05 | KY | MEDICAID | 50002853 | 05 | KY | MEDICAID | 000000259190 | 01 | KY | ANTHEM BC & BS | OTHER |