Provider Demographics
NPI:1205666369
Name:WALLACE, ANSLEY
Entity type:Individual
Prefix:
First Name:ANSLEY
Middle Name:
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 1:112 ROSE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-7239
Mailing Address - Country:US
Mailing Address - Phone:706-473-5303
Mailing Address - Fax:
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program