Provider Demographics
NPI:1013040666
Name:WALLACE, SHANA DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANA
Middle Name:DALE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANA
Other - Middle Name:DALE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1390
Mailing Address - Fax:704-384-1063
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:SUITE 1010
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1122
Practice Address - Country:US
Practice Address - Phone:704-384-1390
Practice Address - Fax:704-384-1063
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-010632080P0008X
NC2004010632084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907566Medicaid
NC200401063OtherMEDICAL LICENSE