Individual
MELLANI MARITZA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
613 MARQUETTE RD, BRANDON, MS 39042-3038
(601) 591-5553
Mailing address
5749 RAYMOND BOLTON RD, BOLTON, MS 39041-9253
(601) 968-7032
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Enumeration date
04/10/2021
Last updated
04/10/2021
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