Individual
MS. DONETTA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C
Contact information
Practice address
336 N MAYO TRL, PAINTSVILLE, KY 41240-1804
(606) 789-8666
(606) 788-0253
Mailing address
PO BOX 2379, ASHLAND, KY 41105-2379
(606) 408-9571
(606) 408-6061
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA544
KY
363AM0700X
Medical Physician Assistant
PA544
KY
Other
Enumeration date
08/09/2005
Last updated
02/01/2022
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