Provider Demographics
NPI:1407109309
Name:PROFFITT, SHANA C (ANP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:C
Last Name:PROFFITT
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 1:845 MALCOLM BLVD
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612
Mailing Address - Country:US
Mailing Address - Phone:828-580-3555
Mailing Address - Fax:828-874-2111
Practice Address - Street 1:845 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612
Practice Address - Country:US
Practice Address - Phone:828-580-3555
Practice Address - Fax:828-874-2111
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202133363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407109309Medicaid