Individual
AMY BLAISING WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
1415 S MAIN ST, EATON RAPIDS, MI 48827-1959
(517) 663-4809
Mailing address
3337 BRITTON RD, PERRY, MI 48872-9706
(517) 625-3004
(517) 625-5001
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5101013086
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1356380950
—
MI
05
—
4628183TYPE11
—
MI
Enumeration date
06/06/2006
Last updated
12/17/2018
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