Provider Demographics
NPI:1770627705
Name:WALLACE, KIMBERLY SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHANNON
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 DEFENSE HWY SUITE 201
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054
Mailing Address - Country:US
Mailing Address - Phone:410-721-3200
Mailing Address - Fax:410-721-2680
Practice Address - Street 1:1438 DEFENSE HWY SUITE 201
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054
Practice Address - Country:US
Practice Address - Phone:410-721-3200
Practice Address - Fax:410-721-2680
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD66924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine