Healthcare Provider Details

I. General information

NPI: 1932989357
Provider Name (Legal Business Name): MARYSA P WALLACE AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD NORTON RD STE 200
FAYETTEVILLE GA
30215-4873
US

IV. Provider business mailing address

1835 SAVOY DR STE 203
ATLANTA GA
30341-1073
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-1117
  • Fax: 678-817-0823
Mailing address:
  • Phone: 770-496-9430
  • Fax: 404-891-4947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN259981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: