MEDICARE: GRANT WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN319027	GA

General Provider Information

NPI Number	:	1336006642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT WALLACE

Provider Business Mailing Address
First Line	:	72 WALTHALL ST SE UNIT B
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-1328
Country	:	US
Telephone Number	:	616-438-4241
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 CLIFTON RD NE STE 244
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-4201
Country	:	US
Telephone Number	:	404-727-7980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2026
Last Update Date	:	01/07/2026

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