Provider Demographics
NPI:1245673565
Name:WALLACE, TRESA C (WHNP)
Entity type:Individual
Prefix:
First Name:TRESA
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:WHNP
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Mailing Address - Street 1:100 ORANGE BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1649
Mailing Address - Country:US
Mailing Address - Phone:504-782-0673
Mailing Address - Fax:
Practice Address - Street 1:110 BELLEMEADE BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-2954
Practice Address - Country:US
Practice Address - Phone:504-309-2576
Practice Address - Fax:504-309-2589
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2020-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAAP07277363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology