Healthcare Provider Details

I. General information

NPI: 1093236572
Provider Name (Legal Business Name): JENNA ROSE WALLACE DNP, APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SHEYENNE ST
WEST FARGO ND
58078-2637
US

IV. Provider business mailing address

3122 46TH AVE S
FARGO ND
58104-6658
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4445
  • Fax: 701-234-4456
Mailing address:
  • Phone: 701-520-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR37792
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: