Individual
DEBORAH A WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
1000 MEDICAL CENTER BLVD, LAWRENCEVILLE, GA 30046-0000
(770) 277-3056
(855) 204-5244
Mailing address
PO BOX 551420, FORT LAUDERDALE, FL 33355-1420
(800) 243-3839
(954) 839-2569
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
R040043
GA
367500000X
Certified Registered Nurse Anesthetist
Primary
RN040043
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000511167C
—
GA
Enumeration date
06/14/2006
Last updated
04/29/2014
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