Provider Demographics
NPI:1477262590
Name:WALLACE, SHANTONITT
Entity Type:Individual
Prefix:
First Name:SHANTONITT
Middle Name:
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 1:2209 PULASKI CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-7312
Mailing Address - Country:US
Mailing Address - Phone:229-618-0021
Mailing Address - Fax:
Practice Address - Street 1:2209 PULASKI CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7312
Practice Address - Country:US
Practice Address - Phone:229-618-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor