Provider Demographics
NPI:1205680014
Name:WALLACE, ELIZABETH DENISE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DENISE
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 1:210 N SMALLEY DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-6105
Mailing Address - Country:US
Mailing Address - Phone:404-451-2894
Mailing Address - Fax:
Practice Address - Street 1:210 N SMALLEY DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-6105
Practice Address - Country:US
Practice Address - Phone:140-445-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management