Healthcare Provider Details

I. General information

NPI: 1235087008
Provider Name (Legal Business Name): SHARANDELL RENA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 SW US HIGHWAY 40 # 146
BLUE SPRINGS MO
64014-3232
US

IV. Provider business mailing address

605 SW US HIGHWAY 40 # 146
BLUE SPRINGS MO
64014-3232
US

V. Phone/Fax

Practice location:
  • Phone: 816-479-1426
  • Fax:
Mailing address:
  • Phone: 816-479-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2015022803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: