Individual
MRS. CANDICE E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1000 MEDICAL CENTER BLVD, LAWRENCEVILLE, GA 30045-7694
(678) 442-3317
(678) 442-4416
Mailing address
1260 WILDCLIFF CIR NE, ATLANTA, GA 30329-3473
(678) 442-3317
(678) 442-4416
Taxonomy
Speciality
Code
Description
License number
State
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
030918
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00405468D
—
GA
Enumeration date
01/29/2007
Last updated
07/08/2007
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