Provider Demographics
NPI:1285830414
Name:PHELPS FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:PHELPS FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:BARDIN
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-842-2443
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:
Mailing Address - Fax:
Practice Address - Street 1:204 SMITH AVE
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4458
Practice Address - Country:US
Practice Address - Phone:910-842-2443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC201344OtherAPPROVAL NUMBER,BOM
NCMP0545965OtherDEA NUMBER
NCP09273Medicare UPIN