Provider Demographics
NPI:1376209528
Name:FLAGG, SHAMICHAEL
Entity Type:Individual
Prefix:
First Name:SHAMICHAEL
Middle Name:
Last Name:FLAGG
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 1:1520 IVY MEADOW DR APT 924
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-9035
Mailing Address - Country:US
Mailing Address - Phone:315-876-4664
Mailing Address - Fax:
Practice Address - Street 1:1520 IVY MEADOW DR APT 924
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-9035
Practice Address - Country:US
Practice Address - Phone:315-876-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330094164W00000X
NC091380164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC091380OtherNURSING LICENSE