Healthcare Provider Details

I. General information

NPI: 1316111719
Provider Name (Legal Business Name): MICHELLE WALLACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 VILLAGE CENTER PKWY
STOCKBRIDGE GA
30281-9044
US

IV. Provider business mailing address

2970 BRANDYWINE RD STE 125
ATLANTA GA
30341-5521
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-2593
  • Fax: 770-488-9408
Mailing address:
  • Phone: 404-256-2593
  • Fax: 770-488-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number141727
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number064090
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: