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General NPI Number Information
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NPI Number | 1851047757
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Entity Type | Individual
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Provider Name | BRIANNA WALLACE LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 03/01/2022
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 1400 HIGHWAY 76 E
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City | HIAWASSEE
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State | GA
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Zip | 30546-3960
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Country | US
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Telephone | 706-374-4014
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Fax |
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Provider Business Mailing Address
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Address Line | 2765 MOBILE RD
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City | MC CAYSVILLE
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State | GA
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Zip | 30555-1832
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Country | US
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Telephone | 706-455-0027
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT004335
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License Number State | GA
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