Individual
GRANT WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1520 CLIFTON RD NE STE 244, ATLANTA, GA 30322-4201
(404) 727-7980
Mailing address
72 WALTHALL ST SE UNIT B, ATLANTA, GA 30316-1328
(616) 438-4241
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
RN319027
GA
Other
Enumeration date
01/07/2026
Last updated
01/07/2026
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