Provider Demographics
NPI:1912211681
Name:WALLACE, BRENDA RENEE (RN, MSN, ARNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:RENEE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1406 ROWANTREE DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-4937
Mailing Address - Country:US
Mailing Address - Phone:850-766-9131
Mailing Address - Fax:813-651-3473
Practice Address - Street 1:1406 ROWANTREE DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4937
Practice Address - Country:US
Practice Address - Phone:850-766-9131
Practice Address - Fax:813-651-3473
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9181213364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health