Provider Demographics
NPI:1619521747
Name:SHACKLEFORD, TIARA (FNP)
Entity type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S ELM ST STE 824
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3060
Mailing Address - Country:US
Mailing Address - Phone:336-390-0190
Mailing Address - Fax:336-390-0190
Practice Address - Street 1:301 S ELM ST STE 824
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3060
Practice Address - Country:US
Practice Address - Phone:336-390-0190
Practice Address - Fax:336-390-0190
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC272154163W00000X, 363LF0000X
NC5012068363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily