Provider Demographics
NPI:1962050369
Name:AMADOR WALLACE, BRENDA FAYE (APRN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:FAYE
Last Name:AMADOR WALLACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25311 SINGING RAIN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-6268
Mailing Address - Country:US
Mailing Address - Phone:210-355-8600
Mailing Address - Fax:
Practice Address - Street 1:2115 PLEASANTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1321
Practice Address - Country:US
Practice Address - Phone:210-922-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142489363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily