Healthcare Provider Details

I. General information

NPI: 1245673565
Provider Name (Legal Business Name): TRESA C WALLACE WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 11/22/2025
Certification Date: 11/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N ILLINOIS ST
INDIANAPOLIS IN
46204-1904
US

IV. Provider business mailing address

2000 CANAL ST
NEW ORLEANS LA
70112-3018
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 504-702-3928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAP07277
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: