Healthcare Provider Details

I. General information

NPI: 1437084605
Provider Name (Legal Business Name): SHANNON LAICHE WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

1071 WEST ST
WESSON MS
39191-7714
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-5000
  • Fax:
Mailing address:
  • Phone: 601-883-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number908508
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: