Provider Demographics
NPI:1144790973
Name:WALLACE, MARLYN M
Entity Type:Individual
Prefix:
First Name:MARLYN
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 KLONDIKE RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5660
Mailing Address - Country:US
Mailing Address - Phone:678-558-3106
Mailing Address - Fax:
Practice Address - Street 1:3073 KLONDIKE RD SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5660
Practice Address - Country:US
Practice Address - Phone:678-558-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN182038363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner