Provider Demographics
NPI:1124483532
Name:HARRELL, SHANTA
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:
Last Name:HARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 NORTH CATHERINE STREET
Mailing Address - Street 2:106 HOLLOMAN AVENUE
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910
Mailing Address - Country:US
Mailing Address - Phone:252-642-3606
Mailing Address - Fax:252-513-8230
Practice Address - Street 1:106 HOLLOMAN AVENUE
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910
Practice Address - Country:US
Practice Address - Phone:252-642-3606
Practice Address - Fax:252-513-8230
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-046-025372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion