1225643679 NPI number — MRS. SHAWNA NICOLE WALLACE M.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225643679 NPI number — MRS. SHAWNA NICOLE WALLACE M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
SHAWNA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225643679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1371 WINGED FOOT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APOPKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32712-2386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-335-1704
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
773 S KIRKMAN RD STE 119
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32811-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-496-2192
Provider Business Practice Location Address Fax Number:
407-440-4510
Provider Enumeration Date:
09/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108772400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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