Provider Demographics
NPI:1073233250
Name:WALLACE, SHANNEN MARGARET
Entity Type:Individual
Prefix:
First Name:SHANNEN
Middle Name:MARGARET
Last Name:WALLACE
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 1:544E MINISTERIAL RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4813
Mailing Address - Country:US
Mailing Address - Phone:401-536-7614
Mailing Address - Fax:
Practice Address - Street 1:25 STOREY AVE STE 11
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-1869
Practice Address - Country:US
Practice Address - Phone:978-499-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist