Provider Demographics
NPI:1982430344
Name:WALLACE, BRENDAN
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9345 SW SKOKOMISH LN
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7316
Mailing Address - Country:US
Mailing Address - Phone:971-979-2149
Mailing Address - Fax:
Practice Address - Street 1:9345 SW SKOKOMISH LN
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7316
Practice Address - Country:US
Practice Address - Phone:971-979-2149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK228251163WP0808X
OR202000644RN163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health