NPIMap

Individual provider Active NPI

Ciji Deyuana Wallace, RN-FNP

  • Family Nurse Practitioner
  • Bogalusa, LA
National Provider Identifier
1487455036
Registry record updated Oct 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
240977 Issued in LA
Practice address
219 S Border Dr
Bogalusa, LA 70427-3671
Phone
(985) 633-1952
Fax
(985) 732-4458
NPI assigned
Mar 20, 2025
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 907340 MS
Family Nurse Practitioner 363LF0000X 240977 LA Primary
Registered Nurse 163W00000X 913403 MS

Addresses

Primary practice location

219 S Border Dr
Bogalusa, LA 70427-3671

Mailing address

PO Box 652
MC Neill, MS 39457-0652
Phone (601) 215-6976

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA, MS2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20250806004672 LA Practitioner - Nurse Practitioner 3577061886
I20260430000977 MS Practitioner - Nurse Practitioner 3577061886 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2024
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Memorial Hospital at GulfportGroup PAC ID 2466524012, 473 clinicians
Clinics of the Southeast LLCGroup PAC ID 6709116239, shared by 2 NPIs, 3 clinicians

Practice addresses (Care Compare)

1104 Broad Ave
Gulfport, MS 39501-2414
Phone (228) 822-6811

1340 Broad Ave
Gulfport, MS 39501-2460

1340 Broad Ave
Gulfport, MS 39501-2465

219 S Border Dr
Bogalusa, LA 70427-3671
Phone (985) 633-1952

405 Ave F
Bogalusa, LA 70427-3633
Phone (985) 732-1568

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
913403MSMDRegistered Nurse
240977LAMDFamily Nurse Practitioner
907340MSMDFamily Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Clinics of the Southeast LLC CurrentSince Jul 1, 2025 Accepting new patients
Clinics of the Southeast LLC CurrentSince Jul 1, 2025 Accepting new patients
Memorial Hospital at Gulfport Past Accepting new patients

Locations

405 Avenue F
Bogalusa, LA 70427
Phone (985) 732-1568

219 S Border Dr
Bogalusa, LA 70427
Phone (504) 732-4300

405 Avenue F
#C
Bogalusa, LA 70427
Phone (985) 732-1568

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 60

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 60

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1742428800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1760400000000",
    "number": "1487455036",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 652",
            "city": "MC NEILL",
            "state": "MS",
            "postal_code": "394570652",
            "telephone_number": "601-215-6976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "219 S BORDER DR",
            "city": "BOGALUSA",
            "state": "LA",
            "postal_code": "704273671",
            "telephone_number": "985-633-1952",
            "fax_number": "985-732-4458"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CIJI",
        "middle_name": "DEYUANA",
        "name_prefix": "Mrs.",
        "credential": "RN-FNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2025-03-20",
        "last_updated": "2025-10-14",
        "certification_date": "2025-10-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "907340",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "LA",
            "license": "240977",
            "primary": true
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "MS",
            "license": "913403",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bogalusa, LA

Sources for this page

Verify at the official NPI Registry.