Healthcare Provider Details

I. General information

NPI: 1962050369
Provider Name (Legal Business Name): BRENDA FAYE AMADOR WALLACE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N SAINT PAUL ST STE 3100
DALLAS TX
75201-3923
US

IV. Provider business mailing address

25311 SINGING RAIN
SAN ANTONIO TX
78260-6268
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 210-355-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP142489
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: