Provider Demographics
NPI:1740159730
Name:WALLETTE, BREANNA LEIGH
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEIGH
Last Name:WALLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10017 BIA ROAD 9
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316
Mailing Address - Country:US
Mailing Address - Phone:701-278-0728
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 52
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-0052
Practice Address - Country:US
Practice Address - Phone:701-278-0728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant