Individual
MARYSA P WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGNP-C
Contact information
Practice address
132 OLD NORTON RD STE 200, FAYETTEVILLE, GA 30215-4873
(678) 817-1117
(678) 817-0823
Mailing address
1835 SAVOY DR STE 203, ATLANTA, GA 30341-1073
(770) 496-9430
(404) 891-4947
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
RN259981
GA
Other
Enumeration date
10/03/2023
Last updated
08/14/2024
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