Provider Demographics
NPI:1912549916
Name:WALLACE-ADAMS, DEKOYA
Entity Type:Individual
Prefix:
First Name:DEKOYA
Middle Name:
Last Name:WALLACE-ADAMS
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 1:1505 MADISON HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-6574
Mailing Address - Country:US
Mailing Address - Phone:229-539-4874
Mailing Address - Fax:
Practice Address - Street 1:1804 E PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-4414
Practice Address - Country:US
Practice Address - Phone:229-539-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health