Provider Demographics
NPI:1255468781
Name:PHELPS, SHANNON BARDIN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BARDIN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:FNP
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 1369
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-1369
Mailing Address - Country:US
Mailing Address - Phone:910-842-2443
Mailing Address - Fax:
Practice Address - Street 1:110A VILLAGE RD NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7412
Practice Address - Country:US
Practice Address - Phone:910-371-0055
Practice Address - Fax:910-371-0061
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP09273Medicare UPIN