Provider Demographics
NPI:1801099767
Name:WALLACE, LISA N (LPTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:N
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-1446
Mailing Address - Country:US
Mailing Address - Phone:334-863-6844
Mailing Address - Fax:706-845-3700
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-845-3192
Practice Address - Fax:706-845-3700
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000264225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant