Individual
BRANDI WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
4622 40TH AVENUE SOUTH, SUITE A, FARGO, ND 58104-4394
(701) 364-2909
Mailing address
4500 36TH AVE S STE 100, FARGO, ND 58104-5275
(701) 361-2286
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
149297-030
WI
163W00000X
Registered Nurse
R144003-8
MN
363LF0000X
Family Nurse Practitioner
Primary
R30131
ND
Other
Enumeration date
02/22/2007
Last updated
10/25/2019
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