Provider Demographics
NPI:1518430875
Name:WALLACE, SHAWN MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W WISSAHICKON AVE
Mailing Address - Street 2:
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-1898
Mailing Address - Country:US
Mailing Address - Phone:215-248-7804
Mailing Address - Fax:
Practice Address - Street 1:110 W WISSAHICKON AVE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-1898
Practice Address - Country:US
Practice Address - Phone:215-248-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR235002363L00000X
NJNJDCATEMP-006243363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner