Provider Demographics
NPI:1790559581
Name:WALLACE, SHANNON KAY (NBC-HWC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19504 MARCY ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4850
Mailing Address - Country:US
Mailing Address - Phone:402-871-5295
Mailing Address - Fax:
Practice Address - Street 1:19504 MARCY ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4850
Practice Address - Country:US
Practice Address - Phone:402-871-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty