Newly Listed Provider — this NPI profile has been added to the NPI registry within the last 90 days.

SHANNON LAICHE WALLACE NP
NPI 1437084605
Nurse Practitioner in Vicksburg, MS

Q: What is Shannon Wallace's NPI number?

The NPI number for Shannon Wallace is 1437084605. It was assigned to this individual provider in the NPPES registry on June 17, 2026.

Q: What is Shannon Wallace's specialty?

The primary specialty registered for this NPI is Nurse Practitioner with taxonomy code 363L00000X.

Q: When was this NPI record last updated?

The NPPES record for Shannon Wallace was last updated on June 17, 2026. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 2 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since June 17, 2026PECOS Enrolled

2100 HIGHWAY 61 N, VICKSBURG, MS 39183(601) 883-5000 Get Directions Write a Review

NPPES record added: June 17, 2026. Verified against the NPPES registry weekly; last sync: August 23, 2026.

On this page

About Shannon Laiche Wallace Np NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

SHANNON LAICHE WALLACE NP (NPI 1437084605) is an individual nurse practitioner in Vicksburg, Mississippi, licensed in Mississippi (908508) and active in the NPI registry since June 2026. She is enrolled in Medicare PECOS and is a graduate of Other (2026).

NPPES Registry Identity

NPI1437084605

Entity TypeIndividualFemale

Primary Taxonomy363L00000X

Provider Legal NameSHANNON LAICHE WALLACECredential: NP

Location Address2100 HIGHWAY 61 NVicksburg, MS 39183-8211

Mailing Address1071 West StWesson, MS 39191-7714 · (601) 883-4840

Phone(601) 883-5000

Sole ProprietorYes

Medical School CMSOtherGraduated 2026

Enumeration DateJune 17, 2026

NPPES CertifiedMay 27, 2026

✔ NPI 1437084605 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyNurse PractitionerPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363L00000X

License✔ Licensed in MS · 908508

Definition

(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision making and direct accountability for clinical judgment across the health care continuum or in a certified specialty. (2) A registered nurse who has completed additional training beyond basic nursing education and who provides primary health care services in accordance with state nurse practice laws or statutes. Tasks performed by nurse practitioners vary with practice requirements mandated by geographic, political, economic, and social factors. Nurse practitioner specialists include, but are not limited to, family nurse practitioners, gerontological nurse practitioners, pediatric nurse practitioners, obstetric-gynecologic nurse practitioners, and school nurse practitioners.

2100 HIGHWAY 61 N, Vicksburg, MS 39183

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Group Practice 1

Group TaxonomyThis provdier is a business group of one or more individual practitioners, all of who practice with the same area of specialization.193400000X SINGLE SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Shannon Laiche Wallace Np is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

PECOS PAC ID4688138811

PECOS Enrollment IDI20260709001406

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 39183 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$80.50 typical visit price

range $51.65 – $159.18

Typical copayment $20.12 (range $12.91 – $39.79)

Most-billed visit code 99203

Established Patient

$92.20 typical visit price

range $16.15 – $129.61

Typical copayment $23.05 (range $4.03 – $32.40)

Most-billed visit code 99214

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MR. MICHAEL J MCREYNOLDS CRNA

Nurse Anesthetist, Certified Registered