Provider Demographics
NPI:1164654893
Name:SPEECE, SHANNON IVY (ANP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:IVY
Last Name:SPEECE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9428
Mailing Address - Country:US
Mailing Address - Phone:919-734-1779
Mailing Address - Fax:
Practice Address - Street 1:2609 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9428
Practice Address - Country:US
Practice Address - Phone:919-734-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5449989363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health