MEDICARE: SHARANDELL RENA WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2015022803	MO

General Provider Information

NPI Number	:	1235087008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARANDELL RENA WALLACE

Provider Business Mailing Address
First Line	:	605 SW US HIGHWAY 40 # 146
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3232
Country	:	US
Telephone Number	:	816-479-1426
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 SW US HIGHWAY 40 # 146
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-3232
Country	:	US
Telephone Number	:	816-479-1426
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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Directions to “ SHARANDELL RENA WALLACE ” Practice Location

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