Provider Demographics
NPI:1245856822
Name:WALLACE, ALEXIS NICOLE (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INTERNAL MEDICINE RESIDENCY 1120 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-2273
Mailing Address - Fax:
Practice Address - Street 1:AUGUSTA UNIVERSITY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:1120 15TH ST
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL84507207R00000X
GA12864207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine