Provider Demographics
NPI:1770113441
Name:WALLACE, BRANDY S
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 COUNTY ROAD 127
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-9668
Mailing Address - Country:US
Mailing Address - Phone:601-616-1864
Mailing Address - Fax:
Practice Address - Street 1:6823 SAINT CHARLES AVE BLDG 92
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5665
Practice Address - Country:US
Practice Address - Phone:504-865-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903712363LF0000X
LA215880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily