Individual
JAMIE F WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
735 GLYNN ST S, FAYETTEVILLE, GA 30214-2049
(770) 461-4126
(770) 461-8852
Mailing address
735 GLYNN ST S, FAYETTEVILLE, GA 30214-2049
(770) 461-4126
(770) 461-8852
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
043044
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00794483A
—
GA
Enumeration date
05/27/2006
Last updated
07/08/2007
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