Provider Demographics
NPI:1528257268
Name:WALLACE, CYNTHIA R (CNM)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 DAN PROCTOR DR
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3894
Mailing Address - Country:US
Mailing Address - Phone:912-540-6750
Mailing Address - Fax:912-540-6773
Practice Address - Street 1:2060 DAN PROCTOR DR
Practice Address - Street 2:SUITE 1200
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3894
Practice Address - Country:US
Practice Address - Phone:912-540-6750
Practice Address - Fax:912-540-6773
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN046062367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00668885AMedicaid