Provider Demographics
NPI:1477579688
Name:WALLIS, BRENDA (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151736
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-1736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3120
Practice Address - Country:US
Practice Address - Phone:936-639-3036
Practice Address - Fax:936-639-3064
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX072151367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84275UOtherBCBS
TX84279UOtherBCBS
TX84275UOtherBCBS
TX8C6701Medicare PIN