Provider Demographics
NPI:1053856427
Name:WALLACE, HEATHER E
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
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:PO BOX 26698
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6698
Mailing Address - Country:US
Mailing Address - Phone:478-972-0277
Mailing Address - Fax:
Practice Address - Street 1:535 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-0104
Practice Address - Country:US
Practice Address - Phone:478-972-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN197918363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner