Healthcare Provider Details

I. General information

NPI: 1538111539
Provider Name (Legal Business Name): LUCY-BERTHA WALLANG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 MAIN ST W
SNELLVILLE GA
30078-3161
US

IV. Provider business mailing address

2545 ALEXA CHASE CV
DACULA GA
30019-7578
US

V. Phone/Fax

Practice location:
  • Phone: 770-866-5147
  • Fax:
Mailing address:
  • Phone: 770-866-5147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004665
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number58593
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number026102-01
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9117305
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number200001685
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number124154
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1131-23
License Number StateWI
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004665
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: