Provider Demographics
NPI:1083338198
Name:OUTLAW, JUANITA SHAWNTA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:SHAWNTA
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 BELLA SQ
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-8961
Mailing Address - Country:US
Mailing Address - Phone:252-724-0192
Mailing Address - Fax:
Practice Address - Street 1:293 BELLA SQ
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-8961
Practice Address - Country:US
Practice Address - Phone:252-724-0192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017031363LF0000X
NC197527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily