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General NPI Number Information
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NPI Number | 1255274411
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Entity Type | Individual
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Provider Name | EDNA FELLS WALLACE LPN
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Gender | Female
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Dates
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Enumeration Date | 04/13/2026
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Last Update Date | 04/13/2026
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Provider Practice Location Address
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Address Line | 1555 N. MAIN STREET
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City | FAYETTE
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State | MS
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Zip | 39069
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Country | US
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Telephone | 601-786-8091
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Fax | 601-786-8023
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Provider Business Mailing Address
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Address Line | PO BOX 194
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City | LORMAN
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State | MS
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Zip | 39096-0194
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Country | US
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Telephone | 601-809-8901
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Fax | 601-786-8023
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | P189022
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License Number State | MS
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