Individual
LISA MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
777 HEMLOCK ST, MACON, GA 31201-2102
(478) 633-1000
Mailing address
598 3RD ST, MACON, GA 31201-3357
(478) 633-6706
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
1-097840
AL
Other
Enumeration date
02/26/2008
Last updated
06/05/2015
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