Healthcare Provider Details

I. General information

NPI: 1801465133
Provider Name (Legal Business Name): SHAMIKA D WALLACE RN, BSN, CWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 PARKROW LN
SAN JOSE CA
95132-3537
US

IV. Provider business mailing address

2852 PARKROW LN
SAN JOSE CA
95132-3537
US

V. Phone/Fax

Practice location:
  • Phone: 408-781-7680
  • Fax:
Mailing address:
  • Phone: 408-781-7680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: