Brandi Wallace, FNP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

R30131 Issued in ND

Practice address

4622 40TH Avenue South
Suite a
Fargo, ND 58104-4394

Phone

(701) 364-2909

NPI assigned

Feb 22, 2007

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in ND, MN2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Specialty

Nurse Practitioner

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Innovis Health LLCGroup PAC ID 9931298155, shared by 7 NPIs, 561 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Nurse Practitioner, Nurse Practitioner

State licenses

Practice roles

Locations

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.

• Innovis Health, LLC

  dba Essentia Health Fargo

  • General Acute Care Hospital
  • Fargo, ND
  • NPI 1215125463
  Medicare reassignment NPD
• Innovis Health LLC

  dba Essentia Health Moorhead Clinic

  • Family Medicine Physician
  • Moorhead, MN
  • NPI 1659617504
  Medicare reassignment NPD
• Marciana Group

  dba Mendota Health

  • Medical Specialty Clinic/Center
  • Lakeville, MN
  • NPI 1134719693

  ND

  Medicare reassignment
• Innovis Health LLC

  dba Essentia Health-Osgood Clinic

  • Multi-Specialty Clinic/Center
  • Fargo, ND
  • NPI 1144776576
  NPD
• Innovis Health LLC

  dba Essentia Health West Fargo Clinic

  • Family Medicine Physician
  • West Fargo, ND
  • NPI 1487990339
  NPD
• Innovis Health LLC

  dba Essentia Health-Downtown Moorhead Clinic

  • Multi-Specialty Clinic/Center
  • Moorhead, MN
  • NPI 1164972410
  NPD
• Daniel B Grossman M D Inc

  dba Marciana Group of California

  • Medical Specialty Clinic/Center
  • Orange, CA
  • NPI 1922739366
  NPD (past)

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

{
    "created_epoch": "1172102400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1571961600000",
    "number": "1982739900",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4500 36TH AVE S STE 100",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581045275",
            "telephone_number": "701-361-2286"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4622 40TH AVENUE SOUTH",
            "address_2": "SUITE A",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581044394",
            "telephone_number": "701-364-2909"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4794 50th Ave S",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "581046027",
            "country_code": "US",
            "telephone_number": "701-361-2286",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2800 Cleveland Ave N",
            "address_purpose": "LOCATION",
            "city": "Roseville",
            "state": "MN",
            "postal_code": "551131126",
            "country_code": "US",
            "telephone_number": "651-642-1825",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4141 31st Ave S Ste 102",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "58104",
            "country_code": "US",
            "telephone_number": "701-356-0097",
            "fax_number": "701-356-0061",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4141 31st Ave S Ste 102",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "58104",
            "country_code": "US",
            "telephone_number": "701-356-0097",
            "fax_number": "701-356-0061",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4500 36th Ave S Ste 100",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "581045275",
            "country_code": "US",
            "telephone_number": "701-361-2286",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "4500 36th Ave S Ste 100",
            "address_purpose": "LOCATION",
            "city": "Fargo",
            "state": "ND",
            "postal_code": "581045275",
            "country_code": "US",
            "telephone_number": "701-361-2286",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BRANDI",
        "credential": "FNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-02-22",
        "last_updated": "2019-10-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "MN",
            "license": "R144003-8",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "WI",
            "license": "149297-030",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "ND",
            "license": "R30131",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Samantha Walker, CPHT
• Tracy Kathleen Walker
• Vanessa Renise Walker, NP
• Camille Walkin
• Amanda Wallace, AAS, LPN
• Heather Ann Walleen, RN
• Derek Wallenstein
• Carmen Waller Waller
• Walman Optical Company
• John Walsh, MD

• Family Nurse Practitioner in Fargo, ND
• Providers in Fargo, ND by specialty
• Family Nurse Practitioner in North Dakota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.