Provider Demographics
NPI:1851481584
Name:WALLACE, SHANNON L (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 N RAINEY RD W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-9784
Mailing Address - Country:US
Mailing Address - Phone:317-753-6323
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001501363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ15526Medicare UPIN