Provider Demographics
NPI:1699652511
Name:WALLACE, SHELLEY BROOKE (PA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:BROOKE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4207
Mailing Address - Country:US
Mailing Address - Phone:336-995-8611
Mailing Address - Fax:
Practice Address - Street 1:522 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4207
Practice Address - Country:US
Practice Address - Phone:336-995-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant