1588142574 NPI number — SHANNON WALLACE

Table of content: SHANNON WALLACE (NPI 1588142574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588142574 NPI number — SHANNON WALLACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1588142574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8777 254TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEROSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11426-2329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-324-2766
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8777 254TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEROSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11426-2329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-324-2766
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2018

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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