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Susan R Wallace

Nurse Practitioner

Physician Assistants & Advanced Practice Nursing Providers

100 Methodist Blvd, Hattiesburg, MS 39402-1295

PECOS Enrollment

This provider is enrolled in PECOS as SUSAN WALLACE.

Based on the most recent information from CMS, provider Susan R Wallace is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.

Part B
Medicare Part B
Enrolled
HHA
Home Health Agency
Enrolled
DME
Durable Medical Equipment
Enrolled
PMD
Power Mobility Device
Enrolled

CMS last updated its PECOS records 5 days ago.

Profile Details

Provider ID
1740537687
Provider Type
Individual
Full Name
Wallace, Susan R
Gender
Female

Sole Proprietor
No
Enumeration Date
8/9/2012
Last Updated
8/10/2012

Contact Information

Practice Location

100 Methodist Blvd, Hattiesburg, MS 39402-1295

(601) 268-6738

Unlisted Fax

Mailing Location

100 Methodist Blvd, Hattiesburg, MS 39402-1295

(601) 268-6738

Unlisted Fax

Provider Taxonomies

Code	Description	License
Code 363LF0000X Primary	Description Nurse Practitioner Physician Assistants & Advanced Practice Nursing Providers	License R852101 Mississippi

Susan R Wallace

PECOS Enrollment

Profile Details

Contact Information

Practice Location

Mailing Location

Provider Taxonomies

Code

Description

License

Code

Description

License

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Smith, Brandi Fennell

Hunt, April

Robertson, Sherri A

Roberts, Lauren Nicole

Lacroix, Jennifer Elaine

Barham, Kara Lynne

Delancey, Melinda Bennett

Chatham, Tarah

Miller, Jessica Eustis