Healthcare Provider Details

I. General information

NPI: 1275820235
Provider Name (Legal Business Name): MALISSA WALL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 MCLENDON DR
DECATUR GA
30033-1802
US

IV. Provider business mailing address

1438 MCLENDON DR
DECATUR GA
30033-1802
US

V. Phone/Fax

Practice location:
  • Phone: 770-414-0337
  • Fax: 855-294-1992
Mailing address:
  • Phone: 770-414-0337
  • Fax: 855-294-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number072720
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: