Individual
ELIZABETH DENISE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
210 N SMALLEY DR, VIDALIA, GA 30474-6105
(140) 445-1289
Mailing address
210 N SMALLEY DR, VIDALIA, GA 30474-6105
(404) 451-2894
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Enumeration date
04/16/2024
Last updated
04/16/2024
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