Healthcare Provider Details

I. General information

NPI: 1255274411
Provider Name (Legal Business Name): EDNA FELLS WALLACE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 N. MAIN STREET
FAYETTE MS
39069
US

IV. Provider business mailing address

PO BOX 194
LORMAN MS
39096-0194
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-8091
  • Fax: 601-786-8023
Mailing address:
  • Phone: 601-809-8901
  • Fax: 601-786-8023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP189022
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: