Provider Demographics
NPI:1982739900
Name:WALLACE, BRANDI (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 36TH AVE S STE 100
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5275
Mailing Address - Country:US
Mailing Address - Phone:701-361-2286
Mailing Address - Fax:
Practice Address - Street 1:4622 40TH AVENUE SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4394
Practice Address - Country:US
Practice Address - Phone:701-364-2909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR144003-8163W00000X
WI149297-030163W00000X
NDR30131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse