Basic Information
| Provider Information | |||||||||
| NPI: | 1093236572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3122 46TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581046658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015201852 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 SHEYENNE ST | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580782637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344445 | ||||||||
| FaxNumber: | 7012344456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 07/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R37792 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.