Provider Demographics
NPI:1326563909
Name:HOLTSCLAW, SHANNON LEA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:HOLTSCLAW
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 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:360 BEECH ST
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657-9670
Practice Address - Country:US
Practice Address - Phone:828-733-5889
Practice Address - Fax:828-733-8743
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172290364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult