Individual
DR. SHANA DALE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1900 RANDOLPH RD, SUITE 1010, CHARLOTTE, NC 28207-1122
(704) 384-1390
(704) 384-1063
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-1390
(704) 384-1063
Taxonomy
Speciality
Code
Description
License number
State
2080P0008X
Pediatric Neurodevelopmental Disabilities Physician
2004-01063
NC
2084N0402X
Neurology with Special Qualifications in Child Neurology Physician
Primary
200401063
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
200401063
MEDICAL LICENSE
NC
05
—
5907566
—
NC
Enumeration date
03/13/2007
Last updated
10/25/2020
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