Individual
AMY JO WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
861 OLD WINSTON RD STE 101, KERNERSVILLE, NC 27284-7141
(336) 904-0143
(336) 904-0046
Mailing address
PO BOX 602658, CHARLOTTE, NC 28260-2658
(336) 716-2011
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
200600865
NC
208000000X
Pediatrics Physician
26169
SC
Other
Enumeration date
07/11/2006
Last updated
11/04/2020
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