Provider Demographics
NPI:1104198639
Name:O'SHALL, ERICA MARIE
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:MARIE
Last Name:O'SHALL
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:BOSTIC
Mailing Address - State:NC
Mailing Address - Zip Code:28018-0577
Mailing Address - Country:US
Mailing Address - Phone:321-652-4378
Mailing Address - Fax:
Practice Address - Street 1:503 SOUTH MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:BOSTIC
Practice Address - State:NC
Practice Address - Zip Code:28018-0577
Practice Address - Country:US
Practice Address - Phone:321-652-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7063224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant