Individual
MRS. JAMIE MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
3311 PRESCOTT RD, SUITE 201, ALEXANDRIA, LA 71301-3900
(318) 442-6767
(318) 441-1259
Mailing address
3311 PRESCOTT RD, SUITE 201, ALEXANDRIA, LA 71301-3900
(318) 442-6767
(318) 441-1259
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
TEMP PERMIT
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
APPLIED FOR
—
LA
Enumeration date
08/13/2007
Last updated
08/13/2007
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