Shannon L Wallace, FNP-BC, PMHNP-BC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

71001501 Issued in IN

Practice address

1481 W 10TH St
Indianapolis, IN 46202-2803

Phone

(317) 554-0000

NPI assigned

Oct 13, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Shalom Health Care Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Indianapolis, IN
  • NPI 1992924633

  Family

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160697600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664236800000",
    "number": "1851481584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12670 N RAINEY RD W",
            "city": "SYRACUSE",
            "state": "IN",
            "postal_code": "465679784",
            "telephone_number": "317-753-6323"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1481 W 10TH ST",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462022803",
            "telephone_number": "317-554-0000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "SHANNON",
        "middle_name": "L",
        "credential": "FNP-BC, PMHNP-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-10-13",
        "last_updated": "2022-09-27",
        "certification_date": "2022-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IN",
            "license": "71001501",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "IN",
            "license": "71001501",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mikayla Renee Wallace
• Nicole Wallace
• Patricia Ann Wallace, O.T.
• Royale Wallace
• Savannah Wallace, MSW
• Tresa C Wallace, WHNP
• Alysha Wallen
• Mark Wallen, RBT
• William Wallen, MD
• Bruce F Waller, MD

• Psychiatric/Mental Health Nurse Practitioner in Indianapolis, IN
• Providers in Indianapolis, IN by specialty
• Psychiatric/Mental Health Nurse Practitioner in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.