Provider Demographics
NPI:1851047757
Name:WALLACE, BRIANNA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 MOBILE RD
Mailing Address - Street 2:
Mailing Address - City:MC CAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30555-1832
Mailing Address - Country:US
Mailing Address - Phone:706-455-0027
Mailing Address - Fax:
Practice Address - Street 1:1400 HIGHWAY 76 E
Practice Address - Street 2:
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-3960
Practice Address - Country:US
Practice Address - Phone:706-374-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0043352255A2300X
390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program