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General NPI Number Information
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NPI Number | 1205102092
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Entity Type | Individual
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Provider Name | SHANNON LEIGH WALLACE M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/27/2012
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Last Update Date | 03/10/2020
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Provider Practice Location Address
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Address Line | CLEVELAND CLINIC 9500 EUCLID AVENUE
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City | CLEVELAND
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State | OH
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Zip | 44195-1705
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Country | US
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Telephone | 216-636-8926
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Fax |
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Provider Business Mailing Address
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Address Line | 1470 FRANKS LN
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City | MENLO PARK
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State | CA
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Zip | 94025-5960
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Country | US
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Telephone | 303-880-7809
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Fax |
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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 | 207VF0040X
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Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
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License Number | A149644
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License Number State | CA
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