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General NPI Number Information
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NPI Number | 1003255605
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Entity Type | Individual
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Provider Name | SARA SHEEHAN WALLACE MD
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Gender | Female
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Dates
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Enumeration Date | 06/18/2013
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Last Update Date | 12/14/2020
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Provider Practice Location Address
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Address Line | 3240 SUNSET BLVD
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City | WEST COLUMBIA
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State | SC
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Zip | 29169-3428
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Country | US
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Telephone | 803-359-8855
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Fax | 803-794-6480
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Provider Business Mailing Address
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Address Line | PO BOX 6069
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City | WEST COLUMBIA
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State | SC
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Zip | 29171-6069
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Country | US
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Telephone | 803-359-8855
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Fax | 803-794-6480
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | LL35809
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 35809
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License Number State | SC
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