Provider Demographics
NPI:1326260209
Name:WALLACE, KATIE ETTER (DPT)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:ETTER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 SPRING ST NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3715
Mailing Address - Country:US
Mailing Address - Phone:770-219-8402
Mailing Address - Fax:
Practice Address - Street 1:597 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2545
Practice Address - Country:US
Practice Address - Phone:770-219-8204
Practice Address - Fax:770-219-3862
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist