Provider Demographics
NPI:1114464310
Name:WALLACE, SARA W (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:W
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 UPPER HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1146
Mailing Address - Country:US
Mailing Address - Phone:770-475-2377
Mailing Address - Fax:770-442-0193
Practice Address - Street 1:950 SANDERS RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5960
Practice Address - Country:US
Practice Address - Phone:678-208-2446
Practice Address - Fax:770-887-1375
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN183641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner