Healthcare Provider Details

I. General information

NPI: 1205102092
Provider Name (Legal Business Name): SHANNON LEIGH WALLACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLEVELAND CLINIC 9500 EUCLID AVENUE
CLEVELAND OH
44195-1705
US

IV. Provider business mailing address

1470 FRANKS LN
MENLO PARK CA
94025-5960
US

V. Phone/Fax

Practice location:
  • Phone: 216-636-8926
  • Fax:
Mailing address:
  • Phone: 303-880-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA149644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: