DR. SHANA DALE WALLACE MD NPI 1013040666

NPI Information

NPI: 1013040666
Provider Name: DR. SHANA DALE WALLACE, MD
Classification: Psychiatry & Neurology - 2084N0402X
Entity Type: Individual

Specialization: Neurology with Special Qualifications in Child Neurology

Organization: NOVANT MEDICAL GROUP INC

PECOS Registration: Yes

Address:
1900 RANDOLPH RD
SUITE 1010
CHARLOTTE, NC
ZIP 28207
Phone: (704) 384-1390
Get Directions

DR. Shana Dale Wallace, MD is a neurology with special qualifications in child neurology psychiatry neurology in Charlotte, NC with 22 years of experience. The provider is a Child Neurologist specializes in neurology with special skills in diagnosis and treatment of neurologic disorders of the neonatal period, infancy, early childhood, and adolescence. DR. Shana Dale Wallace, MD NPI is 1013040666. The provider is registered as an individual entity type.

The NPPES NPI record indicates the provider is a female.

Education
Medical School: UNIVERSITY OF SOUTH CAROLINA SCHOOL OF MEDICINE
Graduation Year:2002

The provider's business location address is:

1900 RANDOLPH RD
SUITE 1010
CHARLOTTE, NC
ZIP 28207-122
Phone: (704) 384-1390
Fax: (704) 384-1063

The NPI 1013040666 is registered in the Medicare Provider, Enrollment, Chain and Ownership System (PECOS). The provider is legally eligible to order and refer Part B (Clinical Laboratory and Imaging), Durable Medical Equipment, Part A Home Health Agency (HHA), Power Mobility Devices.

The enumeration date for this NPI number is 3/13/2007 and was last updated on 10/25/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	2080P0008X	Pediatrics	Neurodevelopmental Disabilities	2004-01063	NORTH CAROLINA	No
2	2084N0402X	Psychiatry & Neurology	Neurology with Special Qualifications in Child Neurology	200401063	NORTH CAROLINA	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	5907566	MEDICAID	NORTH CAROLINA
2	200401063	OTHER	NORTH CAROLINA	MEDICAL LICENSE

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/14/2023

NPI Synchronization or Removal

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