Provider Demographics
NPI:1003666199
Name:LEAKE, SHAKIRA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHAKIRA
Middle Name:
Last Name:LEAKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 LONGVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CROSS HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29332-3124
Mailing Address - Country:US
Mailing Address - Phone:864-547-4600
Mailing Address - Fax:
Practice Address - Street 1:117 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3850
Practice Address - Country:US
Practice Address - Phone:864-520-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28569363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health