Provider Demographics
NPI:1205476850
Name:BURKS-WALLACE, SHAWNEE LAIN
Entity type:Individual
Prefix:MRS
First Name:SHAWNEE
Middle Name:LAIN
Last Name:BURKS-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 1:9017 FM 182
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-3439
Mailing Address - Country:US
Mailing Address - Phone:254-206-0906
Mailing Address - Fax:
Practice Address - Street 1:5302 JANELLE DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5666
Practice Address - Country:US
Practice Address - Phone:254-699-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist