Individual
SUSAN R WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
100 METHODIST BLVD, HATTIESBURG, MS 39402-1295
(601) 268-6738
Mailing address
100 METHODIST BLVD, HATTIESBURG, MS 39402-1295
(601) 268-6738
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R852101
MS
Other
Enumeration date
08/09/2012
Last updated
08/10/2012
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