Provider Demographics
NPI:1972181642
Name:HEART OF A PHOENIX ORGANIZATION LLC
Entity type:Organization
Organization Name:HEART OF A PHOENIX ORGANIZATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/ MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWNDELE
Authorized Official - Middle Name:LANIK
Authorized Official - Last Name:DANZY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:803-518-9079
Mailing Address - Street 1:8180 REGENT PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8417
Mailing Address - Country:US
Mailing Address - Phone:803-518-9079
Mailing Address - Fax:704-626-6855
Practice Address - Street 1:8180 REGENT PKWY STE 115
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8417
Practice Address - Country:US
Practice Address - Phone:803-518-9079
Practice Address - Fax:704-626-6855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-01
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP7553Medicaid