Provider Demographics
NPI:1225643679
Name:WALLACE, SHAWNA NICOLE (MA)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNA
Middle Name:NICOLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 WINGED FOOT DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2386
Mailing Address - Country:US
Mailing Address - Phone:407-335-1704
Mailing Address - Fax:
Practice Address - Street 1:773 S KIRKMAN RD STE 119
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-2046
Practice Address - Country:US
Practice Address - Phone:407-496-2192
Practice Address - Fax:407-440-4510
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker