Provider Demographics
NPI:1093069627
Name:EBERT, SHASTA LEANN
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:LEANN
Last Name:EBERT
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 1:5415 PECANBLUFF CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2662
Mailing Address - Country:US
Mailing Address - Phone:704-560-9158
Mailing Address - Fax:336-277-4672
Practice Address - Street 1:125 DAYS INN DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6323
Practice Address - Country:US
Practice Address - Phone:704-660-9111
Practice Address - Fax:704-663-4504
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2024-01-03
Deactivation Date:2022-02-03
Deactivation Code:
Reactivation Date:2022-02-23
Provider Licenses
StateLicense IDTaxonomies
NC5005908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily