1922396696 NPI number — SUSAN STACKER SHEALY APRN MSN CPNP PC

Table of content: SUSAN STACKER SHEALY APRN MSN CPNP PC (NPI 1922396696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922396696 NPI number — SUSAN STACKER SHEALY APRN MSN CPNP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEALY
Provider First Name:
SUSAN
Provider Middle Name:
STACKER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN MSN CPNP PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922396696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2224 OLD FURNACE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOILING SPRINGS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29316-5782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-578-8720
Provider Business Mailing Address Fax Number:
864-599-5675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1307 N LOGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAFFNEY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29341-2026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-488-1333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2011

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: 363LP0200X , with the licence number:  APN.17546 RX , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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