Provider Demographics
NPI:1811715493
Name:WALLACE, STEPHANIE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1581 CAROL SUE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:844-677-2968
Mailing Address - Fax:
Practice Address - Street 1:1581 CAROL SUE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:844-677-2968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA237784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily