Provider Demographics
NPI:1750757340
Name:WALLACE, SHANNON (HOME HEATH AIDE)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:HOME HEATH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CANDYCE AVE
Mailing Address - Street 2:SAME
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-1202
Mailing Address - Country:US
Mailing Address - Phone:863-614-4071
Mailing Address - Fax:
Practice Address - Street 1:636 CANDYCE AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-1202
Practice Address - Country:US
Practice Address - Phone:863-614-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide