Marysa P Wallace, AGNP-C

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

RN259981 Issued in GA

Practice address

132 Old Norton Rd Ste 200
Fayetteville, GA 30215-4873

Phone

(678) 817-1117

Fax

(678) 817-0823

NPI assigned

Oct 3, 2023

Last updated

Aug 14, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Mercer University School of Medicine, 2016

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

NSH Cancer Institute Professional Services G LLCGroup PAC ID 0840443164, 115 clinicians

Practice addresses (Care Compare)

Merit-based Incentive Payment System (MIPS)

Final score

71.19 of 100Reported as group

Quality

69.24

Improvement activities

40

Cost

51.37

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: marysa.wallaceagnpc.p1@direct.gacancer.nextgenshare.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• NSH Cancer Institute Professional Services G, LLC

  • Hematology & Oncology Physician
  • Sandy Springs, GA
  • NPI 1144571381
  Medicare reassignment Care Compare group NPD
• NSH Cancer Institute Professional Services G LLC

  • Durable Medical Equipment & Medical Supplies
  • Blue Ridge, GA
  • NPI 1629329792
  NPD
• Northside Imaging LLC

  • Diagnostic Radiology Physician
  • Warner Robins, GA
  • NPI 1316394976
  NPD (past)
• NSH Cancer Institute Professional Services G, LLC

  • Hematology & Oncology Physician
  • Atlanta, GA
  • NPI 1124379284
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1696291200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1723593600000",
    "number": "1932989357",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1835 SAVOY DR STE 203",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303411073",
            "telephone_number": "770-496-9430",
            "fax_number": "404-891-4947"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "132 OLD NORTON RD STE 200",
            "city": "FAYETTEVILLE",
            "state": "GA",
            "postal_code": "302154873",
            "telephone_number": "678-817-1117",
            "fax_number": "678-817-0823"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARYSA",
        "middle_name": "P",
        "credential": "AGNP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-10-03",
        "last_updated": "2024-08-14",
        "certification_date": "2024-08-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "GA",
            "license": "RN259981",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "marysa.wallaceagnpc.p1@direct.gacancer.nextgenshare.com",
            "affiliation": "N",
            "endpointDescription": "Direct Address",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Direct Edge",
            "address_1": "132 Old Norton Rd Ste 200",
            "city": "Fayetteville",
            "state": "GA",
            "country_code": "US",
            "postal_code": "302154873",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Walgreen Co (Rite Aid #11761)
• Walgreen Co (Walgreens #06372)
• Sarah M Walker
• Victoria Walker, MD
• Jamie F Wallace
• Tyjaih Wallace
• Jacob Wallis
• Renita Walls, FNP
• Connie M Ward, PHD
• Kara Ward, RBT

• Nurse Practitioner in Fayetteville, GA
• Providers in Fayetteville, GA by specialty
• Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.