Provider Demographics
NPI:1184667388
Name:WALLACE, DEBORAH A (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-0000
Practice Address - Country:US
Practice Address - Phone:770-277-3056
Practice Address - Fax:855-204-5244
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR040043367500000X
GARN040043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000511167CMedicaid
GA2021436907Medicare PIN
GAS41056Medicare UPIN
GA000511167CMedicaid