Individual
HEATHER E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
535 COLISEUM DR, MACON, GA 31217-0104
(478) 972-0277
Mailing address
PO BOX 26698, MACON, GA 31221-6698
(478) 972-0277
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
RN197918
GA
363LG0600X
Gerontology Nurse Practitioner
Primary
RN197918
GA
Other
Enumeration date
12/21/2016
Last updated
12/27/2016
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