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Individual

AMANDA DANIEL WALLACE

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
PA-C

Contact information

Practice address
655 JESSE JEWELL PKWY SE STE B, GAINESVILLE, GA 30501-3854
(770) 532-7092
(770) 536-0383
Mailing address
PO BOX 658, GAINESVILLE, GA 30503-0658
(770) 718-1122
(770) 533-4786

Taxonomy

Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
6247
GA
363AM0700X
Medical Physician Assistant
6247
GA
363AS0400X
Surgical Physician Assistant
Primary
6247
GA

Other

Enumeration date
09/13/2011
Last updated
09/26/2023
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