Shannon Wallace

NPI #1588142574 in Bellerose, New York

Provider Information

NPI Number: 1588142574
Entity Type: Individual
Name: Shannon Wallace
Gender: Not Specified
Sole Proprietor: No
Primary Specialty: Specialist
Enumeration Date: Aug 1, 2018
Last Updated: Sep 13, 2018

Practice Location

Address: 8777 254TH ST
City: Bellerose
State: New York
ZIP Code: 11426-2329
Phone: (347) 324-2766

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Specialist	174400000X	Primary

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