Provider Demographics
NPI:1255578068
Name:WALLACK, SHANNON MARIE (CRNA)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:WALLACK
Suffix:
Gender:F
Credentials:CRNA
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5129
Mailing Address - Fax:
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN517367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered