MEDICARE: BRANDI WALLACE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R144003-8	MN
2	163W00000X	Registered Nurse	149297-030	WI
3	363LF0000X	Family Nurse Practitioner	R30131	ND

General Provider Information

NPI Number	:	1982739900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI WALLACE FNP

Provider Business Mailing Address
First Line	:	4500 36TH AVE S STE 100
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-5275
Country	:	US
Telephone Number	:	701-361-2286
Fax Number	:

Provider Business Practice Location Address
First Line	:	4622 40TH AVENUE SOUTH
Second Line	:	SUITE A
City	:	FARGO
State	:	ND
Zip	:	58104-4394
Country	:	US
Telephone Number	:	701-364-2909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	10/25/2019

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