Provider Demographics
NPI:1225502412
Name:WALLACE, SHERITA DANIELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHERITA
Middle Name:DANIELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SHERITA
Other - Middle Name:DANIELLE
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3514 HIGHWAY 39 N STE A&B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1305
Mailing Address - Country:US
Mailing Address - Phone:601-512-1310
Mailing Address - Fax:833-984-3427
Practice Address - Street 1:3514 HIGHWAY 39 N STE A&B
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1305
Practice Address - Country:US
Practice Address - Phone:601-512-1310
Practice Address - Fax:833-984-3427
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902938363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00786527Medicaid