Individual
MARLYN M. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3073 KLONDIKE RD SW, CONYERS, GA 30094-5660
(678) 558-3106
Mailing address
3073 KLONDIKE RD SW, CONYERS, GA 30094-5660
(678) 558-3106
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
RN182038
GA
Other
Enumeration date
12/05/2018
Last updated
12/05/2018
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