Provider Demographics
NPI:1114808110
Name:WALLACE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name: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 1:31835 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-9080
Mailing Address - Country:US
Mailing Address - Phone:210-589-0046
Mailing Address - Fax:
Practice Address - Street 1:31835 EMERALD DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-9080
Practice Address - Country:US
Practice Address - Phone:210-589-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula