Provider Demographics
NPI:1538111539
Name:WALLANG, LUCY-BERTHA (PA-C)
Entity type:Individual
Prefix:
First Name:LUCY-BERTHA
Middle Name:
Last Name:WALLANG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 ALEXA CHASE CV
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7578
Mailing Address - Country:US
Mailing Address - Phone:770-866-5147
Mailing Address - Fax:
Practice Address - Street 1:2675 MAIN ST W
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3161
Practice Address - Country:US
Practice Address - Phone:770-866-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58593363AM0700X
NY026102-01363AM0700X
FL9117305363AM0700X
DC200001685363AM0700X
IA124154363AM0700X
WI1131-23363AM0700X
GA004665363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA723874491AMedicaid
GA11143OtherBLUE CROSS BLUE SHIELD
GA723874491BMedicaid
GA01076922OtherAMERIGROUP
GA333656OtherWELLCARE
GA723874491Medicaid
GA723874491BMedicaid
GA723874491AMedicaid