KELLI PETERSON WALLACE MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN AND SURGEON

License Number

036102829

License Status

NOT RENEWED

Business

First Name

KELLI

Middle

PETERSON

Last Name

WALLACE

Suffix

Business Name

KELLI PETERSON WALLACE MD

Original Issue Date

06/24/2000

Effective Date

06/24/2000

Expiration Date

07/31/2002

City

O FALLON

State

Zip

62269

County

SAINT CLAIR

Ever Disciplined

LastModifiedDate

10/09/2006