DR. SHANA DALE WALLACE (NPI# 1013040666) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1013040666 |
| Entity Type | Individual |
| Full Name | DR. SHANA DALE WALLACE |
| Other Name | DR. SHANA DALE GREEN |
| Credential | MD |
| Practice Address |
1900 Randolph Rd Suite 1010 Charlotte NC 28207-1122 |
| Mailing Address |
Po Box 60447 Charlotte NC 28260-0447 |
| Practice Telephone | 7043841390 |
| Practice Fax Number | 7043841063 |
| Mailing Telephone | 7043841390 |
| Mailing Fax Number | 7043841063 |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2020-10-25 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 2080P0008X |
Pediatrics Specialization: Neurodevelopmental Disabilities |
2004-01063 | NC | Allopathic & Osteopathic Physicians |
| Y | 2084N0402X |
Psychiatry & Neurology Specialization: Neurology with Special Qualifications in Child Neurology |
200401063 | NC | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| NC | 5907566 | 05 | |
| NC | MEDICAL LICENSE | 200401063 | 01 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1922665173 | Shana Wallace | Social Worker | 150 South Ave # 2, Lewiston, ME 04240-5759 | 2019-05-23 |
| Street Address |
1900 RANDOLPH RD SUITE 1010 |
| City | CHARLOTTE |
| State | NC |
| Zip Code | 28207-1122 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1881689362 | Barbara Elizabeth Kissam | Pediatrics | 1900 Randolph Rd, Suite 1010, Charlotte, NC 28207-1122 | 2005-09-12 |
| 1144769332 | Courtney Wiseman | Physician Assistant | 1900 Randolph Rd, Suite 800, Charlotte, NC 28207-1122 | 2017-02-21 |
| 1700339785 | Yu Wei Shan | Nurse Practitioner | 1900 Randolph Rd, Suite 800, Charlotte, NC 28207-1122 | 2016-07-26 |
| 1891182127 | Novant Medical Group,inc | Pediatrics | 1900 Randolph Rd, Suite 300, Charlotte, NC 28207-1122 | 2015-04-24 |
| 1578979936 | Kristen Elizabeth Bush | Physician Assistant | 1900 Randolph Rd, Ste 900, Charlotte, NC 28207-1122 | 2014-07-07 |
| 1003235524 | Novant Medical Group Inc | Internal Medicine | 1900 Randolph Rd, Suite 216, Charlotte, NC 28207-1122 | 2014-04-11 |
| 1508107863 | Novant Medical Group Inc | Internal Medicine | 1900 Randolph Rd, Suite 300, Charlotte, NC 28207-1106 | 2013-03-12 |
| 1639422264 | Anthony James Mignanelli II | Nurse Practitioner | 1900 Randolph Rd, Suite 900, Charlotte, NC 28207-1122 | 2012-10-19 |
| 1851642169 | Meagan Marie Bullock | Social Worker | 1900 Randolph Rd, Suite 800, Charlotte, NC 28207-1122 | 2012-09-26 |
| 1114299294 | Worley Shaun Lynch | Physician Assistant | 1900 Randolph Rd, Suite 900, Charlotte, NC 28207-1122 | 2012-02-03 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1013560739 | Louis Roncaglione | Dentist | 8815 Christenbury Pkway, Concord, NC 28207 | 2019-07-22 |
| 1619430014 | Khrystyna Levytska | Student in an Organized Health Care Education/Training Program | Myers Park Clinic Ob/gyn, 1350 S. Kings Dr., Charlotte, NC 28207 | 2019-04-11 |
| 1649743584 | Carolinas Hometown Respiratory LLC | Durable Medical Equipment & Medical Supplies | 1005 South Kings Drive, Charlotte, NC 28207 | 2019-01-03 |
| 1023584489 | Herron and Smith Associates, Pllc | Dentist | 135 Perrin Place, Suite 100, Charlotte, NC 28207 | 2018-10-23 |
| 1588161640 | Lauren Mogk | Student in an Organized Health Care Education/Training Program | Myers Park Clinical Internal Medicine, 1350 S. Kings Dr., 3rd Floor, Charlotte, NC 28207 | 2018-04-06 |
| 1518462241 | Sarah Hollyn Carlock | Student in an Organized Health Care Education/Training Program | Myers Park Clinic Internal Medicine, 1350 S Kings Dr, 3rd Floor, Charlotte, NC 28207 | 2018-03-26 |
| 1083118178 | Claire Milam | Student in an Organized Health Care Education/Training Program | Cmc/department of Emergency Medicine, 100 Blythe Blvd, Charlotte, NC 28207 | 2018-03-22 |
| 1811422256 | Complete Care At Dartmouth LLC | Skilled Nursing Facility | 300 Province Road, Charlotte, NC 28207 | 2017-04-24 |
| 1063945467 | Kaitlyn O'keefe | Internal Medicine | 1350 S. Kings Dr., 3rd Floor, Myers Park Clinic Internal Medicine, Charlotte, NC 28207 | 2017-04-04 |
| 1811432024 | Advanced Prosthetics of Easley, Inc | Durable Medical Equipment & Medical Supplies | 2310 Randolph Rd Ste A, Charlotte, NC 28207 | 2016-12-23 |
| Find all providers in zip 28207 | ||||
| Taxonomy Code | 2084N0402X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Psychiatry & Neurology |
| Specialization | Neurology with Special Qualifications in Child Neurology |
| A Child Neurologist specializes in neurology with special skills in diagnosis and treatment of neurologic disorders of the neonatal period, infancy, early childhood, and adolescence. |
| Notes: Source: The American Board of Psychiatry and Neurology, Inc. www.abpn.com [1/1/2007: new definition] |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1033675079 | Novant Medical Group Inc | Psychiatry & Neurology | 1918 Randolph Rd Ste 320, Charlotte, NC 28207-1109 | 2019-02-14 |
| 1023415981 | The Charlotte-mecklenburg Hospital Authority | Psychiatry & Neurology | 12311 Copper Way, Suite 200-a, Charlotte, NC 28277-3642 | 2014-11-20 |
| 1073932885 | Neurology Wellness, Pllc | Psychiatry & Neurology | 10508 Park Rd, Ste 130, Charlotte, NC 28210-8525 | 2014-04-09 |
| 1780011825 | The Charlotte-mecklenburg Hospital Authority | Psychiatry & Neurology | 2608 E 7th St, Charlotte, NC 28204-4375 | 2013-10-03 |
| 1518394659 | The Charlotte-mecklenburg Hospital Authority | Psychiatry & Neurology | 101 E W T Harris Blvd, Bldg 3000 Ste 3301b, Charlotte, NC 28262-3485 | 2013-10-03 |
| 1720415946 | The Charlotte-mecklenburg Hospital Authority | Psychiatry & Neurology | 1001 Blythe Blvd, Ste 200, Charlotte, NC 28203-5866 | 2013-10-02 |
| 1922367077 | Carolinas Medical Center-northeast | Psychiatry & Neurology | 4501 Cameron Valley Pkwy, Suite 301-a, Charlotte, NC 28211-4297 | 2012-05-10 |
| 1699060384 | Carolinas Medical Center-northeast | Psychiatry & Neurology | 101 E W T Harris Blvd, Bldg 3000, Suite 3301b, Charlotte, NC 28262-7000 | 2011-06-10 |
| 1972806321 | Cmc-northeast, Inc. | Psychiatry & Neurology | 1001 Blythe Blvd, Suite 200 Cpnc - Charlotte Specialty Center, Charlotte, NC 28203-5866 | 2010-12-07 |
| 1265747497 | Cmc-northeast, Inc. | Psychiatry & Neurology | 1010 Edgehill Rd N, Carolinas Pediatric Neurology Care - Charlotte, Charlotte, NC 28207-1885 | 2010-08-12 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.