1972856706 NPI number — MRS. SHANNON TARA ORMSBEE APRN

Table of content: MRS. SHANNON TARA ORMSBEE APRN (NPI 1972856706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972856706 NPI number — MRS. SHANNON TARA ORMSBEE APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORMSBEE
Provider First Name:
SHANNON
Provider Middle Name:
TARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITTEMORE
Provider Other First Name:
SHANNON
Provider Other Middle Name:
TARA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972856706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 TIMBERLAKE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-779-7128
Provider Business Mailing Address Fax Number:
910-908-7738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WAMC CLARK HEALTH CLINIC
Provider Second Line Business Practice Location Address:
BLDG 5-4257 BASTOGNE STREET
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-2575
Provider Business Practice Location Address Fax Number:
910-908-7738
Provider Enumeration Date:
10/17/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  005158 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5009248 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)