Healthcare Provider Details

I. General information

NPI: 1720640162
Provider Name (Legal Business Name): SONYA COUTEE WALLACE WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2019
Last Update Date: 07/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 HIGHLANDS PKWY SE STE 420
SMYRNA GA
30082-5192
US

IV. Provider business mailing address

3239 BOROGROVE WAY
DECATUR GA
30032-5980
US

V. Phone/Fax

Practice location:
  • Phone: 678-424-1123
  • Fax:
Mailing address:
  • Phone: 404-218-5475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN163190
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: