Provider Demographics
NPI: | 1851481584 |
---|---|
Name: | WALLACE, SHANNON L (FNP-BC, PMHNP-BC) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHANNON |
Middle Name: | L |
Last Name: | WALLACE |
Suffix: | |
Gender: | F |
Credentials: | FNP-BC, PMHNP-BC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 12670 N RAINEY RD W |
Mailing Address - Street 2: | |
Mailing Address - City: | SYRACUSE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46567-9784 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-753-6323 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1481 W 10TH ST |
Practice Address - Street 2: | |
Practice Address - City: | INDIANAPOLIS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46202-2803 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-554-0000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-13 |
Last Update Date: | 2022-09-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 71001501 | 363LF0000X, 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | Q15526 | Medicare UPIN |