Healthcare Provider Details

I. General information

NPI: 1386181022
Provider Name (Legal Business Name): MEGAN WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 W PARK PLACE BLVD STE A
STONE MOUNTAIN GA
30087-3543
US

IV. Provider business mailing address

2240 W PARK PLACE BLVD STE A
STONE MOUNTAIN GA
30087-3543
US

V. Phone/Fax

Practice location:
  • Phone: 770-771-5222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN231247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: