Active NPI
Kathryn Mary Wallace, APRN, BC
- Nurse Practitioner
- Portage, IN
National Provider Identifier
1407965320
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 71000473A
- Practice address
- 2640 Hamstrom Rd
Portage, IN 46368-3832 - Phone
- (219) 762-4423
- Fax
- (219) 763-3120
- NPI assigned
- Aug 30, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 71000473A | IN | Primary |
Addresses
Primary practice location
2640 Hamstrom Rd
Portage, IN 46368-3832
Mailing address
2640 Hamstrom Rd
Portage, IN 46368-3832
Phone (219) 762-4423
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200056120A | Medicaid | IN | |
| 500004228 | Other | IN | RAILROAD MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 71000473A | IN | MD | Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1347840000000",
"number": "1407965320",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2640 HAMSTROM RD",
"city": "PORTAGE",
"state": "IN",
"postal_code": "463683832",
"telephone_number": "219-762-4423",
"fax_number": "219-763-3120"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2640 HAMSTROM RD",
"city": "PORTAGE",
"state": "IN",
"postal_code": "463683832",
"telephone_number": "219-762-4423",
"fax_number": "219-763-3120"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KATHRYN",
"middle_name": "MARY",
"credential": "APRN, BC",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-30",
"last_updated": "2012-09-17",
"status": "A"
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "IN",
"license": "71000473A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200056120A",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "500004228",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Portage, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 17, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.