Individual
LATAUNYA B WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
102 WOODCHASE PARK DR, CLINTON, MS 39056-4113
(601) 924-7043
(601) 924-8633
Mailing address
359 BROOKWOOD LAKE PL, JACKSON, MS 39272-5648
(601) 924-7043
(601) 924-8633
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT1460
MS
Other
Enumeration date
04/06/2010
Last updated
04/06/2010
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