Healthcare Provider Details

I. General information

NPI: 1982739900
Provider Name (Legal Business Name): BRANDI WALLACE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 40TH AVENUE SOUTH SUITE A
FARGO ND
58104-4394
US

IV. Provider business mailing address

4500 36TH AVE S STE 100
FARGO ND
58104-5275
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-2909
  • Fax:
Mailing address:
  • Phone: 701-361-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR144003-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number149297-030
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR30131
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: