Provider Demographics
NPI:1366014854
Name:MARTIN, SHAKYRA TATYANA
Entity type:Individual
Prefix:
First Name:SHAKYRA
Middle Name:TATYANA
Last Name:MARTIN
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 1:1799 EDGEFIELD RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-5306
Mailing Address - Country:US
Mailing Address - Phone:803-341-8343
Mailing Address - Fax:
Practice Address - Street 1:1799 EDGEFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-5306
Practice Address - Country:US
Practice Address - Phone:803-341-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC133N00000X, 133NN1002X, 171400000X, 226300000X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No171400000XOther Service ProvidersHealth & Wellness Coach
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC302611321Medicaid
SC850000309Medicaid