Individual
SHANNON LAICHE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
2100 HIGHWAY 61 N, VICKSBURG, MS 39183-8211
(601) 883-5000
Mailing address
1071 WEST ST, WESSON, MS 39191-7714
(601) 883-4840
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
908508
MS
Other
Enumeration date
06/17/2026
Last updated
06/17/2026
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