Individual
MS. SHANNON MARIE WALLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
435 PHALEN BLVD, SAINT PAUL, MN 55130-5302
(651) 254-8080
Mailing address
8170 33RD AVE S # MS 21110Q, BLOOMINGTON, MN 55425-4516
(952) 883-5129
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
517
MN
Other
Enumeration date
01/15/2009
Last updated
12/17/2024
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