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General NPI Number Information
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NPI Number | 1487455036
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Entity Type | Individual
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Provider Name | CIJI DEYUANA WALLACE RN-FNP
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Gender | Female
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Dates
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Enumeration Date | 03/20/2025
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Last Update Date | 10/14/2025
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Provider Practice Location Address
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Address Line | 219 S BORDER DR
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City | BOGALUSA
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State | LA
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Zip | 70427-3671
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Country | US
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Telephone | 985-633-1952
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Fax | 985-732-4458
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Provider Business Mailing Address
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Address Line | PO BOX 652
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City | MC NEILL
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State | MS
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Zip | 39457-0652
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Country | US
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Telephone | 601-215-6976
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 907340
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 240977
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 913403
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License Number State | MS
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